1. CHEROKEE NATION Cherokee Elder Care (PACE) Melissa Gower, Group Leader Health Services & Government Relations

2. WHAT IS PACE? Programs of All-Inclusive Care for the Elderly Provides and coordinates all needed preventive, primary, acute and long term care services so that older individuals can continue living in their community. An integrated system of care for the frail elderly that is: Community-based Comprehensive Capitated Coordinated

3. WHAT IS PACE? Optional benefit under both Medicare and Medicaid that focuses entirely on older people who are frail enough to meet their state’s standards for nursing home care. Features comprehensive medical and social services that can be provided at an adult day health center, at home, or an inpatient facility. For the majority of participants, this means they continue to live at home while receiving services, rather than being institutionalized. A team composed of a physician, nurse, social worker and other health professionals assess the participants, develop care plans, and deliver all services.

4. PACE INTERDISCIPLINARY TEAM Care Needs Assessment, Planning and Delivery Primary Care Transportation Personal Care Activities Home Care Pharmacy Nursing Nutrition Social Services OT/PT/Speech

5. ELIGIBILITY Participants must meet the following criteria: 55 years of age or older Live in the PACE service area Meet nursing home level of care requirements as determined by DHS Able to live safely in the community at the time of enrollment Sign and agree to the terms of the enrollment agreement

6. SERVICES PACE manages all of the medical, social, and rehab services participants require. Minimum services: Primary care Social services Restorative therapies Personal care/supportive services Nutritional counseling Recreational therapy Meals Transportation Prescription drugs

7. SERVICES Individual PACE sites may offer additional services unique to their site Services are generally provided in an adult day health center setting, but may also be provided in the home or other therapeutic setting. The PACE team has contact with most participants on a daily basis and all participants several times per week, which assists the team in detecting subtle changes in the participants condition.

8. PAYMENT For participants who have Medicare and Medicaid eligibility there is not charge for PACE services. PACE receives a capitated monthly payment per participant from Medicare and Medicaid. Persons enrolled in PACE who are not Medicare or Medicaid eligible may have a monthly premium.

9. The PACE Model History First Demonstration Sites Operational 1986 Legislation Authorizing PACE Demonstration 19901997 Congress Authorizes Permanent Provider Status Balanced Budget Act of 1997, H.R. 2015 Washington, D.C. (Nov) 1999 Publication of Interim Final PACE Regulation First Program Achieves Permanent PACE Provider Status (Nov) 2001

10. The PACE Model Philosophy Honors what frail elderly want…  To stay in familiar surroundings  To maintain independence  To maintain function  To maintain cultural connections

11. WHY IS PACE A GOOD FIT FOR CHEROKEE NATION? Frail elder populations in rural areas are at higher risk of institutionalization Current environment supports service integration Emerging flexibility supports adaptation

12. BENEFITS FOR THE ELDER Keeps elders in their homes, with families and in their communities. Provides excellent, comprehensive health care with consistent health care providers. Involves the elder and their families in decision making regarding health care and other lifestyle choices. (Partnership) All team approved healthcare costs are covered for enrollees.

13. CULTURAL BENEFITS PACE does not dictate how the building looks, so it can reflect the communities’ culture. By keeping the elder in the community we facilitate holding on to the culture through their knowledge and practices. PACE offers the opportunity for inter-generational activities. The PACE site can incorporate cultural activities, language and art.

14. CEC ARTWORK

15. PACE CHALLENGES TRIBAL OR RURAL COMMUNITIES Lack of population density Shortage of providers Less negotiating power with contract health providers in rural areas vs. urban areas AI/AN are at higher risk for chronic diseases

16. PACE INNOVATIONS TRIBAL OR RURAL COMMUNITIES Use of adjunct sites Use of new technologies Expanded populations (disabled, children, Veterans) Risk sharing/Stop Loss for outliers Caregiver and health professional mix

17. PACE ISSUES TRIBAL SITES IHS does not recognize an integrated system of care such as PACE--only its individual components PACE programs must serve all Medicare/Medicaid, cannot restrict to tribal citizens 100% FMAP applies to Certain Medicaid Services

18. PACE ISSUES TRIBAL SITE Being the first PACE in Oklahoma, Medicaid plan required amendment Methodology to determine an “Indian rate” by the State Negotiation of PACE services under a self- governance or self-determination agreement for 100% FMAP

19. Cherokee Nation’s Pursuit of PACE

20. CHEROKEE NATION SERVICE AREA

21. PLANS FOR PACE DEVELOPMENT Cherokee Nation PACE currently serves the population residing around the Tahlequah area Eventual service area will be the Tribal Jurisdiction Service Area (TJSA). Functions as a traditional PACE program serving all eligible individuals Uses strategies developed under the Rural PACE Expansion grant to address rural areas

22. PLANS FOR PACE DEVELOPMENT Feasibility study utilized conservative PACE rate, rather than any expected “Indian” rate Cherokee Nation created a governmental agency specifically to operate the PACE project – Cherokee Comprehensive Care Agency Organizational rules under PACE are very specific and can be burdensome

23. PLANS FOR PACE DEVELOPMENT Will continue discussions with IHS in order to access purchasing contracts like 340 b and have coverage under the Federal Tort Claims Act While the Nation already maintains provider contracts for many areas of care, those specifically needed for LTC must be negotiated, as well as contracts with IHS as a provider

24. CHEROKEE ELDER CARE New facility construction began April 2007 Opened September 2008 Continuing to work with OHCA and DHS on processes Continue conversations with HIS Enrollment currently at 80, with capacity 135-150

25. August 2006 April 2007 August 2008

26. Interested in Learning More About Establishing a PACE Site in Your Area? Phone: 918-453-5554 E-Mail: rick-richards@cherokee.org Website: http://eldercare.cherokee.org