overview of pace and on lok lifeways on lok presentation to the institute for senior living april...
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OVERVIEW OF PACE AND ON LOK LIFEWAYS
On Lok Presentation to the Institute for Senior Living
April 13, 2012
2Presentation to the Institute for Senior Living April 13, 2012
WHAT IS ON LOK?
Original Vision: • Help the low-income seniors in Chinatown/North Beach area
of San Francisco stay in their own homes with health and social services needed to maintain independence
• National prototype for the Program of All-inclusive Care for the Elderly (PACE) model of care
Structure Today:• On Lok Lifeways, our PACE program, serves almost 1,200
frail seniors in three San Francisco Bay Area Counties • On Lok’s 30th Street Senior Center services over 5,000
seniors annually with traditional senior center services• Owns and operates three housing facilities
Presentation to the Institute for Senior Living April 13, 2012
WHAT IS PACE?PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY
Comprehensive services for the frail elderly: Preventive care Primary care Medications Acute care Long-term care, including
nursing facility when needed
Capitation funding (per member per month): Combines Medicare, Medicaid, private Program has full financial risk (with no carve-outs)
Alignment of care needs and financial interests Monitors elders closely – takes action early to restore health,
control cost
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WHO BENEFITS FROM PACE?
Frail older people who want to live in the community
Family members caring for an elder
Providers who want to deliver seamless, high quality care
Senior housing facilities where elders age in place
Policy makers seeking to save tax-payer money and deliver effective care
Presentation to the Institute for Senior Living April 13, 2012
WHO DOES PACE SERVE?
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Eligibility: 55 years or older Resident of PACE service
area State-certified to need nursing
home level care Can live safely in community
at time of enrollment
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ON LOK’S PACE PARTICIPANT PROFILE
Profile of typical participant Female; average age of 83 16 medical conditions Dependent in 3.7 ADLs (bathing, dressing, etc.) Dependent in 6.7 out of 7 IADLs (medication
management, money management, etc.) Has some degree of cognitive impairment (62%) Dually-eligible for Medicare & Medi-Cal (94%) Enrolled in program last 5.6 years of life
Serves culturally and linguistically diverse population 62% Asian/Pacific Islander, 20% Caucasian,
12% Hispanic, 5% African American, 1% Other Multi-lingual participants and staff
Presentation to the Institute for Senior Living April 13, 2012
ON LOK LIFEWAYS: PACE OPERATIONS
Provider Operations include: Eight PACE centers and 9 Interdisciplinary Teams Home care services, transportation, dietary services Primary care providers (physicians and nurse practitioners) Complete network of contract inpatient and specialty
providers: hospitals, nursing homes, specialty care, lab,x-ray, pharmacy, etc.
Health Plan Functions include: Marketing/Member Enrollment: Member services,
enrollment, disenrollment Complaint, grievance and appeals processes Network management/contract services Quality assurance and Improvement program Electronic health records Claims processing
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HOW DOES PACE WORK?
Interdisciplinary teams assess need, deliver & manage care across settings:
Primary
Care
Transportation
Home Care
Nursing
OT/PT
Speech
Nutrition
Recreation
Social Servic
e
Settings• PACE Center• Home• Acute Hospital
• Nursing Home
Presentation to the Institute for Senior Living April 13, 2012
PACE TEAM APPROACH TO CARE MANAGEMENT
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IDT meets regularly: each participant is assessed at least semi-annually with his/her care plan updated at each interval and with a significant change in condition
The goal is to maximize medical management in the outpatient setting – participants are seen timely in clinic to address new issues
The team coordinates information and transitions between hospital and nursing home
Address person-centered values for end-of-life care
Electronic Health Record supports person-centered care planning
Presentation to the Institute for Senior Living April 13, 2012
MEDICAL MANAGEMENT
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The goal is to maximize medical management in outpatient setting and integrate social and functional support needs with IDT
Primary care team on-site: MD, NP, RN
Full-service clinic for urgent care and management of chronic conditions IV and Respiratory therapy Wound care management Frequent visits for management of chronic disease such as CHF,
diabetes, chronic lung disease
Effective delivery of end-of-life care Discussion of advance healthcare directives to promote end of
life care based on the values of the person
24 hour call system with on-call physicians and nurses linking to IDT
Presentation to the Institute for Senior Living April 13, 2012
WHAT DIFFERENCE
DOES THE PACE MODEL MAKE?
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*CY 2011 On Lok**2008 Medicare Data except Readmission data***2010 http://www.managedcaredigest.com
Presentation to the Institute for Senior Living April 13, 2012
ON LOK PACE OUTCOMES SUMMARY
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Medical Home: 100% of participants have a medical home with a primary care physician and interdisciplinary team responsible for coordinating and providing direct care.
Lower inpatient utilization: Acute care utilization is comparable to the Medicare population even though PACE enrolls an exclusively frail population.
Better follow-up after acute care stay: Readmission rate to acute hospital within 30 days of discharge is half the Medicare average.
End of Life Care: Vast majority of participants remain enrolled through end of life care: 96%
High Rates of Community Residence: 93% reside in the community rather than a nursing home.
High Consumer Satisfaction: In 2011, 93% of participants interviewed at California PACE programs reported that they were very satisfied with the program and 95% reported that would refer a close friend to the program.
Presentation to the Institute for Senior Living April 13, 2012
MEDICARE/MEDI-CAL ELIGIBILITY
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Presentation to the Institute for Senior Living April 13, 2012
ON LOK PACE SOURCES OF REVENUES
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Presentation to the Institute for Senior Living April 13, 2012
PACE RATE-SETTING METHOD
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Medicare Parts A/B: Risk-adjusted for each enrollee by
demographic and diagnostic characteristics, plus frailty adjustor
Part D: Bid premium, risk-adjusted for each enrollee; year-end reconciliation with risk-sharing
Medicaid 90% of fee-for-service cost equivalent for comparable
long-term care population (California W&I §14593(e).)
Presentation to the Institute for Senior Living April 13, 2012
HOW ON LOK PACE DOLLARS ARE SPENT
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Note: Percentages represent proportion of total service revenues for FY10-11 ($88.9M) Medical Loss Ratio = 91%
Presentation to the Institute for Senior Living April 13, 2012
DISTRIBUTION OF SERVICE EXPENSES
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Note percentages represent proportion of total service expenses for FY10-11 ($80.8M)
Presentation to the Institute for Senior Living April 13, 2012
FEDERAL POLICY ENVIRONMENT IN PACE
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National Trends for PACE Tremendous growth in recent years
86 approved PACE organizations in 29 states 16 applications pending with applications in 2 new states
PACE innovations in serving rural areas, veterans, etc.
Medicare Payment Methodology and Reporting Encounter reporting implementation planned for 2013
PACE Flexibility Proposal Modifying the current PACE Model
Expanded use of community physicians Alternative care settings Greater flexibility in IDT composition Expanding PACE to new populations Disabled individuals under the age of 55 years Nursing home residents transitioning back to community
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MEDICARE & MEDI-CAL SERVICES
Hospital Services Physician Services Limited SNF Rehab services Home health services Kidney dialysis Durable medical
equipment (DME) Prescription drugs Hospice
Medi-Cal Medicare cost-sharing (Part B
premiums, deductibles) Medical transportation, vision,
expanded mental/ behavior health services
Long-term skilled nursing facility care
Community-Based LTSS (IHSS, MSSP, ADHC/CBAS)
Other HCBS waiver services
Medicare
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PACE VS. TRADITIONAL MANAGED CARE
Enrolls only nursing home eligible beneficiaries - a small subset of total population
PACE is both an insurer and provider of care
Benefit package includes all Medicare and Medi-Cal services
Covers all home and community-based services (HCBS) and institutional long-term care
Payments are set based on cost of comparable population with services delivered regardless of payment source
Enrolls large numbers of Medi-Cal or Medicare beneficiaries based on eligibility categories
Traditional insurance model – contracts and pays for services
Benefit package includes Medicare or Medi-Cal medical services
Does not cover HCBS services or institutional long-term care services beyond short-stay
Payments are set based on actual costs of providing covered benefits (e.g., Medicare benefit package)
PACE Managed Care
Presentation to the Institute for Senior Living April 13, 2012
CALIFORNIA PACE DEVELOPMENT
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Operating PACE organizations: AltaMed Senior Buena Care serving East Los Angeles and
surrounding communities Centers for Elder Independence serving Alameda and
Contra Costa Counties On Lok Lifeways serving San Francisco, Alameda (Tri-City)
and Santa Clara Counties St. Paul’s PACE serving San Diego County Sutter Senior Care serving Sacramento County
PACE organizations in development Seven organizations have submitted PACE Provider
Application (PPA) to DHCS
Four additional organizations submitted letters of intent to develop PACE
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CHALLENGES
Ensuring PACE is a choice for eligible individuals in counties where Medi-Cal managed care exists
Ensuring that PACE-eligible individuals have timely access to services in the enrollment process
Establishing a PACE Medi-Cal rate-setting methodology that reflects the unique characteristics of the model and provide adequate rates
Significant capital investment is needed to develop facilities, maintain operations and expand PACE centers, unlike traditional managed care plans
Streamlining burdensome regulatory requirements including Shortening application and start-up processes
Need to implement flexbilities to bring PACE to scale
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OPPORTUNITIES
PACE encompasses goals of federal and state health reform
Person-centered care based on shared decision-making and values-based choices for people with chronic diseases and long-term needs.
True “medical home” that is available to the individual and their family/caregivers – 24 hours/day, 7 days/week.
Full integration of all health care services on ongoing basis, across delivery settings through an interdisciplinary team to facilitate care transitions.
Provider accountability for quality and quantity of all services provided.
Payment method which incentivizes the right care, at the right time, in the right place.
California PACE programs have infrastructure for expansion
State leadership can expand PACE, a proven model of acute and long-term care integration for low-income, frail older adults
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INNOVATION AND
BUSINESS DEVELOPMENT
And…beyond PACE
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BUSINESS DEVELOPMENT GOALS
INNOVATION GROWTH
EFFICIENCY SUSTAINABILITY
Presentation to the Institute for Senior Living April 13, 2012
10%
30%
60%
PACE Flexibility & Ex-pansion
Government & Foundation Initiatives/RFPs
New Initiatives
DEPARTMENT FOCUS
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POLICY & PRACTICE DRIVERS
Population Size
Longevity
Diversity
Aging in Place
Chronic Disease
Economic Security
Caregiving
Technology
• Long term services and
supports• Housing
• Health Care• Caregiver
Support• Financing
Presentation to the Institute for Senior Living April 13, 2012
Presentation to the Institute for Senior Living April 13, 2012
EMERGING TRENDS AND TENSIONS
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Decreased Financing
& Increased Demand
Aging in Community
Integrated Systems of
Care
Decentralized Services
New Roles for Medical
Groups
Social and Non-
medical Supports
Presentation to the Institute for Senior Living April 13, 2012
AGING IN COMMUNITY
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Older
Adult
Housing
Medical care/care
coordination
Non-medical supports
Community
Technology
Caregiver support
Presentation to the Institute for Senior Living April 13, 2012
FUTURE UNKNOWNS
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How will the state continue to
support PACE?
Presentation to the Institute for Senior Living April 13, 2012
FUTURE UNKNOWNS
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NEW BUSINESS DEVELOPMENT
(NON-PACE)
What do older adults and their caregivers need? What do they want?
What can they pay for? What are they willing to pay for?
How will “it” be created? How will “it” be paid for? What role will insurance
play? How will the private sector
respond?
Presentation to the Institute for Senior Living April 13, 2012
SO … WHERE WE ARE HEADED?
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• Build on On Lok’s strong reputation and core strengths
• Target populations - Pre-PACE, middle income, Medicare
• New products, partnerships, and lines of business
Well elder to end of life - care management/care coordination, flexible service packages, consumer choice
Presentation to the Institute for Senior Living April 13, 2012
OUR OPPORTUNITY
OUR CHALLENGE
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What do Consumers
Want?
What is Flexible &
Not Dependent
on Government Funding?
What is Viable &
Sustainable?
INNOVATION
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Q & A AND WRAP UP
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