Community Based Care for Older Adults with Complex Needs: The PACE Program Matthew McNabney, MD Medical Director, Hopkins ElderPlus June 25, 2016

Objectives for today Briefly describe the development and current status of PACE Discuss how PACE experience informs other efforts to serve rural elders Review the importance of team training and development in this regard

Program of All-inclusive Care for Elderly (PACE) Comprehensive, team-based care for nursing home (NH) eligible, community-dwelling older adults Coordinated through a day health center Integrated (Medicare & Medicaid) financing that is capitated (“full risk”) Complete accountability for health care

PACE The PACE Center Activities Medical Services Rehab

PACE: Interdisciplinary Teams Care Needs Assessment, Planning and Delivery Social Services Home Care Pharmacy Nutrition OT/PT Primary Care Transportation Personal Care Activities Nursing

PACE Nationally Over 110 sites; 35,000+ participants National PACE Association – Coordinates national PACE data and legislative/policy priorities Recognized as a model of integrated care by CMS Cost-effectiveness evaluated* (Mathmatica 2014) Longer median survival (4.2 yrs) vs. Medicaid waiver (3.5 yrs) and NH (2.3 yrs) – Weiland (2010)

Hopkins ElderPlus (HEP) Opened in 1996 Owned by Johns Hopkins Health System 150 participants (patients) 64 staff (low staff turnover) Serve 16 zip codes in SE/E are of Baltimore city and county

Successes of HEP High satisfaction (I-SAT scores); low disenrollment Low hospitalization – HEP ( ): 2276 days/1000 prt/year – National (Median): 2892 Low NH rate – HEP ( ): 3.7 % – National (Median) 6.7 %

Successes of HEP Leadership in long-term care – Campus – State – National Education of health care providers – Multidisciplinary – Geriatrics…in full display

Challenges for HEP (and PACE) Slow expansion – Start-up – Funding (state support) – Risk Conveying a convincing message to MA/MC Split financing (Medicare and Medicaid) – Variation in financial benefit; silos of funding

How is PACE different from other models of care? Medicaid waiver programs Medicare Advantage plans Special needs plans (SNP) VA programs Comprehensive ambulatory medical practices – “Patient-centered medical homes”

What moves us forward…. Demographic imperative (“do something”) Olmstead Decision Preference of community-based care (outside of nursing homes) Measurable successes Evidence of preference for model (low disenrollment) Reputation and recognition – BBA ‘97, DRA ‘05, Federal Register

What holds us back….. Start-up costs Team staffing -Start-up (and maintenance) Center-based model (geographic limitations) Switch of primary care physician Uncertainty of financial impact on Medicaid – “woodwork effect” – is it real??

Rural Health Issues (General) Dispersed population of older adults Scarcity of providers, expertise Geographic variability Economic issues

PACE Rural Health Initiative 2006: – Final Regulation published in November. Congress awards grants of $500,000 to 15 organizations for rural PACE expansion The need for flexibility within PACE organizations serving rural areas in adapting the PACE model was ultimately recognized in both statute and regulation

The Rural PACE Technical Assistance Program Funded by HRSA’s Office of Rural Health Policy and the Bureau of Health Professions Operated by the National PACE Association in partnership with the National Rural Health Association

Types of flexibility that may be important in rural areas Use of non non-staff, community community-based primary care physicians Composition of PACE IDT Recognition that PACE Centers in rural areas may be different than those in urban settings and utilized less Use of alternative delivery settings Personnel requirements Requirements prohibiting governing body members members’ direct or indirect interest in contracts

PACE for the non-Medicaid population Assets or monthly income that exceeds the Medicaid financial eligibility for PACE (150% of poverty line in Maryland) Monthly “private pay” option (set amount) Think long-term care insurance

PACE for those under 55 A different population of disabled Service line will likely be different (within boundaries of the model) Differences in family dynamics and life station

Important Contacts PACE - CMS (Centers for Medicare and Medicaid Services) –

Summary PACE is addresses key issues facing frail older adults Cost of care and targeting of services is still an important consideration Potential for growth: middle income, rural areas, younger than 55