The presentation will begin shortly.

Caring For Vulnerable Populations 2011 AHA Committee on Research Report

Who are Dual Eligibles? 9.2 million Americans are dual eligibles: Medicaid beneficiaries who are also enrolled in Medicare. While 6 in 10 are 65 or older, more than 1/3 are younger individuals with disabilities. As compared to traditional Medicare beneficiaries, dual eligibles are: 15% more likely to have a cognitive or mental impairment 50% more likely to have diabetes 600% more likely to reside in a nursing facility 250% more likely to have Alzheimer’s disease 100% more likely to have heart disease Much less likely to receive specific measures of preventive care, follow-up care or testing Sources: Kasper, Judy, Molly O’Malley, and Barbara Lyons. “Chronic Disease and Co-Morbidity Among Dual Eligibles: Implications for Patterns of Medicaid and Medicare Service Use and Spending.” Kaiser Commission on Medicaid and the Uninsured, http://www.kff.org/medicaid/8081.cfm, July, 2010. Milligan, CJ et al. “Medicare Advantage Special Needs Plans for Dual Eligibles: A Primer,” The Commonwealth Fund, February 2008. Grabowski, DC. “Special Needs Plans and the Coordination of Benefits and Services for Dual Eligibles,” Health Affairs, 28 no. 1(2009): 136-146.

Since Dual Eligibles Use More Health Care Services . . . Health service utilization among dual eligibles as compared to Medicare population Source: Kasper, Judy, Molly O’Malley, and Barbara Lyons. “Chronic Disease and Co-Morbidity Among Dual Eligibles: Implications for Patterns of Medicaid and Medicare Service Use and Spending.” Kaiser Commission on Medicaid and the Uninsured, July, 2010. Accessed at: http://www.kff.org/medicaid/8081.cfm,

…They Account for a Disproportionate Share of Spending Dual Eligibles as a Share of 2006 Medicare Population and Spending Dual Eligibles as a Share of 2007 Medicaid Population and Spending Dual Eligibles Non Duals Source: Kaiser Family Foundation, “The Role of Medicare for the People Dually Eligible for Medicare and Medicaid,” January 2011. http://www.kff.org/medicare/upload/8138.pdf

Program of All-Inclusive Care for the Elderly Existing Service Delivery Models Lack Coordination at the Provider Level Program Financing Population Care Coordination Special Need Plans Risk-adjusted, capitated payments to cover all Medicare services (each plan determines Medicaid involvement) 298 plans serving more than 1,000,000 beneficiaries Patient ease through one plan Greater budget predictability Multidisciplinary care team No proven care improvement Varying degree of Medicaid coordination Program of All-Inclusive Care for the Elderly Separate Medicare and Medicaid capitated benefit at an agreed-upon per member per month rate 71 sites nationally, servicing approximately 23,000 participants Fully integrated funding stream Established quality measures Medical and nonmedical capabilities Sufficient up-front capital required High administration and workforce costs Centered on one physical location Medicaid Managed Care Some plans maintain FFS with additional payment for coordination; others use capitated model Approximately 2.5 million beneficiaries Incremental step toward risk sharing Improved care coordination FFS disincentives remain No set design standard Some exclusion of long-term care and behavioral health benefits Sources: (1) Milligan, C et al. “Medicare Advantage Special Needs Plans for Dual Eligibles: A Primer.” The Commonwealth Fund. February, 2008. (2) Centers for Medicare and Medicaid Services. Special Needs Plan Comprehensive Report: Medicare Advantage/ Part D Contract and Enrollment Data, Special Needs Plan Data. Accessed at: http://www.cms.gov/(3) McNabney, M. “Program of All-Inclusive Care for the Elderly” (presentation, American Hospital Association Committee on Research, Chicago, IL, March 2011). (4) Petigara, T et al. “Program of All-Inclusive Care for the Elderly.” Health Policy Monitor. April, 2009.

Affordable Care Act Offers Opportunities to Improve Dual Care Coordination The Federal Coordination Health Care Office will study and analyze the best methods to integrate dual benefits, improving coordination between the federal and state governments. The Center for Medicare and Medicaid Innovation will test innovative payment and service delivery models to improve quality and reduce unnecessary costs. In April it was announced the selection of 15 states to receive financial assistance to improve care coordination across sites of care for the dual eligible population.

Hospital Strategies to Care for Duals Incorporate Several Essential Elements 1 Complete assessments and reassessments Align financial incentives 7 2 Incorporate person-centered care principles Develop network and community partnerships 8 3 Implement protocol-based planning Provide nonhealth care services 9 4 Conduct periodic visits Offer home-based care 10 5 Utilize team-based care management Organize center-based day care 11 6 Facilitate data sharing and integrated information systems Incorporate cultural competency and equity of care standards 12 Offer home-based care

Key Take-Away: Caring for Vulnerable Populations While financial alignment may occur at a policy level, hospitals are well positioned to address the system, provider, and patient barriers impeding high-quality care for the most vulnerable populations. Report available at: www.aha.org/caring AHA Committee on Research: http://www.aha.org/research/cor/index.shtml

© 2011 American Hospital Association. All rights reserved © 2011 American Hospital Association. All rights reserved. All materials contained in this publication are available to anyone for download on www.aha.org, www.hret.org, or www.hpoe.org for personal, noncommercial use only. No part of this publication may be reproduced and distributed in any form without permission of the publisher, or in the case of third party materials, the owner of that content, except in the case of brief quotations followed by the above suggested citation. To request permission to reproduce any of these materials, please email HPOE@aha.org.

Program of All-Inclusive Care for the Elderly (PACE) Presentation to the American Hospital Association Matthew McNabney, MD Chair, Research Committee, National PACE Association Medical Director, Hopkins ElderPlus February 7, 2012

Objectives for today Briefly describe the development and current status of this national model of care Provide 2012 update on Hopkins ElderPlus (HEP), the only PACE site in Maryland Discuss how PACE experience informs other efforts to serve the dual-eligible population

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 Nationally 84 sites; 23,000 participants National PACE Association Coordinates national PACE data and legislative/policy priorities Recognized as a model of integrated care by CMS Cost-effectiveness proven* (Abt and associates, 1998) 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 2010 - 2011: 3908 days/1000 prt/year Trend: 2300 - 2800 Low NH rate 2010 - 2011: 7.2% Trend: 5 - 8%

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??

Lessons Learned Several evaluations and approaches undertaken Goal: learn and refine to improve care for participants and viability of model

Recommendations for hospitals considering PACE Explore your network of providers Explore your service area – right population? Think down the road, think diverse portfolio Don’t underestimate the challenges of staffing the required PACE team (number and skills) Consider this a long-term venture with secondary benefits It is the right thing for older people in need

Strategic plan for your geographic service area (re: dual-eligibles) What services do hospitals and health systems need to develop to serve the complex needs of Medicaid and Medicare-Medicaid dual-eligible populations? Participate/support housing and in-home care (which relates to adherence to care) Without it, care (and outcomes) will suffer Counseling and service coordination for “Pre-Medicaid” older adults on Medicare Lack of planning before “spend-down” to MA Strategic plan for your geographic service area (re: dual-eligibles) Limited access to care can lead to inappropriate service utilization

Limitations in the access to (non-ER) care How does the management of Medicaid and Medicare-Medicaid dual-eligible populations integrate within larger efforts to reduce potentially avoidable readmissions? Limitations in the access to (non-ER) care Primary care Home care Community-based services (adult day care, senior centers) Poverty issues may limit resources in community New meds/co-pays, proximity of pharmacies

Caring for Vulnerable Populations Julia Conrad, Vice President Fairview Partners, Senior Services, Fairview Health Services HRET Educational Webinar Presentation February 7, 2012

Who is Fairview Partners? Fairview Partners is a collaborative partnership that offers comprehensive and coordinated care management for seniors living in assisted living sites, long term care centers and in their own home.

Fairview Partners Model Assume full operational responsibility for continuum of care Improve care delivery and promote integration Improve customer satisfaction and clinical outcomes Restructure inter-organizational relationships Reduce inappropriate hospitalizations and identify contributing factors Restructure financing system to lower costs and align incentives

Our Care Model Types 1 – Long term care centers (how we started) 2 – Assisted living sites (we moved to where the seniors moved) 3 – In their own homes (community case management for those on special needs plan: Minnesota Senior Health Options (MSHO))

Fairview Partners Clinical Model Person-centric Integrated Care and Service Hospital Assisted Living SNF Community Programs Rehab Facility/TCU PRIMARY CARE TEAM Adult Day Care Adult Foster Care Home Health Sr. Companions

Partnership Risk sharing Total Cost of Care SNF Partner Selection Primary Care Model Transitions in Care Financial incentives aligned Shared Savings

Fairview Partners Financial Model

Our Success

Our Success * Patient and family satisfaction: * Question: Would you recommend Fairview Partners to your family or friends?

Our Success Reduced our hospital admit/1000 rates: CY 2009 CY 2010 Skilled Nursing Facility 392.2 333.6 Community 533.8 451.4 Assisted Living 472.6 268.8 Prevented 102 hospitalizations in CY 2009 - 2010 by utilizing In-Lieu-of-Day in the SNF setting

Our Success Fairview Transitional Care Network (TCN) 2010 9 SNF TCU's in 7 county metro Cared for around 4,000 patients 97% satisfaction scores 9% hospital readmission rate Saved system $9.5 million dollars (2001 - 2010)

Cost Savings Assisted Living Cost Savings Total savings by direct TCU admit per episode = $7,500 (the approximate cost of a hospitalization/ER/ambulance); 2010 episodes = 9; Total Savings = $67,500 Skilled Nursing Facility Cost Savings Average hospitalization/ER/ambulance = $7,500; Average In Lieu Of Day Cost = $1,500 Average savings per episode = $6,000; Total savings = $246,000 Medication Review Cost Savings Cost savings of $345,000 Pharmacy Costs 2008 2009 2010 Paid Claims $1,718,351 $1,458,983 $1,372,605 Per Member Per Month $457 $388 $363

Where is Fairview Partners Today? Focus on managing frail elderly in community Assisted living Transitional Care Network Electronic medical record Telehealth Predictive software technology Continuum services Community and church relations Federal and state regulatory environment

Lessons Learned and Future of Model Relationships with partners key Joint decision making Monitoring for blips in data Technology to manage health Yearly rate negotiation Real time data base – three months too late Know marketplace Good strategy and governance board

Thank you For further information: Julie Conrad Vice President, Fairview Partners 3400 W 66th Street, Suite 290 Edina, MN 55435 jconrad1@fairview.org 952-914-1751