1. The presentation will begin shortly.

2. Caring For Vulnerable Populations
2011 AHA Committee on Research Report

3. 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, July, Milligan, CJ et al. “Medicare Advantage Special Needs Plans for Dual Eligibles: A Primer,” The Commonwealth Fund, February Grabowski, DC. “Special Needs Plans and the Coordination of Benefits and Services for Dual Eligibles,” Health Affairs, 28 no. 1(2009):

4. 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, Accessed at:

5. …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

6. 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, (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: 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.

7. 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.

8. Hospital Strategies to Care for Duals Incorporate Several Essential Elements1
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

9. 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:
AHA Committee on Research:

10. © 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 or 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

11. 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

12. 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

13. 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

14. 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)

15. 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

16. Successes of HEP High satisfaction (I-SAT scores); low disenrollment
Low hospitalization
: days/1000 prt/year
Trend:
Low NH rate
: %
Trend: %

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

18. 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

19. 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”

20. 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

21. 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??

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

23. 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

24. 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

25. 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

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

27. 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.

28. 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

29. 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))

30. 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

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

32. Fairview Partners Financial Model

33. Our Success

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

35. 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
by utilizing In-Lieu-of-Day in the SNF setting

36. 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 ( )

37. 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

38. 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

39. 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

40. Thank you
For further information: Julie Conrad Vice President, Fairview Partners 3400 W 66th Street, Suite 290 Edina, MN