nicheprogram.org • 2016 Annual NICHE Conference • Care Across the Continuum 1

Keeping up the PACE:Educating Nurses about Programs of All-inclusive Care for the Elderly

NICHE Conference 2016

Carrie Hays McElroy, MSN-HCA, RN, Gero-BC, ACM

VP Clinical Operations/CNO ,TH PACE

Marty Cunningham, MSN, RN, MBA, CCRN

Health Center Manager, Saint Francis LIFE

What is PACE?

• The Program of All-inclusive Care for the Elderly:

• Designed to provide the entire continuum of care and services

to frail seniors, helping them to maintain their independence in

their home and community for as long as possible

• PACE is a permanent Medicare/Medicaid benefit that a senior

may opt into in lieu of a traditional Medicare plan

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In some States PACE Organizations are known by the term “LIFE”

– Living Independently For Elders

PACE Origins

• 1970s– On Lok Demonstration Project• Designed to meet needs of aging San Francisco Bay area

residents

• On Lok is Cantonese for "peaceful, happy abode."

• 1990s—Expansion and replication of model earns PACE name and permanent designation as Medicare/Medicaid benefit• 1994 11 PACE Organizations (PO’s)

• 1996 21 PO’s

• 2007 42 PO’s

• 2010 75 PO’s

• 2014 104 PO’s

Source: NPA. (2015). Pace in the states.

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2016 - 116 PACE Programs Operating in 32 States

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Serving more than 34,000 older adults and expanding…

Trinity Health Operates PACE Plans in Eight States

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CA

AZ

NV

OR

MT

MN

NE

SD

ND

ID

WY

OK

KSCO

UT

TX

NMSC

FL

GAALMS

LA

AR

MO

IA

VA

TN

IN

KY

IL

MI

WV

WA

OH

PA

NY

VT

ME

CT

NJ

D.C.

WINH

MA

RI

MD

NC

AK

HI

Trinity Health PACE Organizations

Working with NICHE to pilot in the PACE Environment

Payment Model

©2015 Trinity Health PACE - Livonia, Mich. 6

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• Payment features are unique compared to other health care payment models

• Integrated Capitated Payment System (per member per month)

• Determined by Frailty and Healthcare Risk scores

• Fully at risk

• Combines funding from multiple sources to meet all participant needs

Medicare Part A & B

Medicare Part D

Medicaid or Private Pay

Who Pays?

Pooled Capitation (PMPM)

Medicare Part D

Medicare Medicaid

Private Pay

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PACE: Key Points

Traditional Model:Fragmentation

PACE Model:Integration

Care

• Multiple providers

• Discontinuity across sites

Financing

• Multiple payors

• Institutional bias

• Restrictions

• Fee for Service drives $$$

Care

• Outpatient care

• Acute care

• Long-term care

Financing

• All-inclusive

• Full risk

• No restrictions

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Prescriptions

OTC MedsPCPs

Home Care

Services

Outpatient

ServicesInpatient

Hospitalization

Rehab and

Equipment

Specialty

PhysicianADHC

Participant and Family PACE Interdisciplinary Team

Assisted

Living

Nursing

Home

Respite

Care

Transportation

All-Inclusive Care = All-Inclusive Payment

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55 years of age or older

Live in a PACE service area

Be certified as eligible to receive nursing home level of care (as determined by the State)

Be able to live safely in the community at point of enrollment

PACE Eligibility Criteria

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2015 PACE Innovation Act will allow CMS to develop pilot projects for

the PACE model to be used as a platform for innovation to serve more

seniors as well as younger individuals in need of integrated care and

services

• Opened:

• February 2013

• Current census:

• 173 Participants

• Marty Cunningham

• Health Center Manager

Saint Francis LIFE, Wilmington, DE

11Copyright © 2014 CHE Trinity Health

Background

©2015 Trinity Health PACE - Livonia, Mich. 12

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• Research in 2015

• Literature Review

- One scholarly peer reviewed article regarding nurses/nursing in PACE

• Needs assessment/pretest

- Result

- Post presentation improvement in knowledge

• Personal Experience

- Parent organization

- Students at LIFE for clinical experience

13©2015 Trinity Health PACE - Livonia, Mich.

Research

Why should nurses know about PACE programs and if they exist in their area?!?

• Nurses are patient advocates

• Nurses are essential in discharge planning

• Nurses know who is safe (or not)

• Nurses know their “frequent flyers”

• Nurses are famous for saying “they need to just put him in a nursing home”

• What if he had PACE support??

Clinical Model

©2015 Trinity Health PACE - Livonia, Mich. 15

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• PACE services• Primary Care

• Episodic Care, Specialist Care

• Social Services

• Adult Day

• Recreation

• PT/OT

• In home services

• Dietary services (dietician assessment/ recommendations, hot meals in center, supplements)

• Transportation

So, what does PACE do for seniors…..exactly?

Source: Saint Francis Healthcare, 2015.

Services, cont.

• When one joins a PACE program they agree to use the program’s PCP and also utilize in-network specialists contracted with the program (PACE plan also = managed care organization)

• All medical, social, rehab, and in-home care is provided and coordinated by the program

• All needs are met via the PACE plan including DME and all medications (part D benefit)

Source: CMS, 2011.

Who really benefits from PACE programs?

• Pt. 85 female, lives with daughter, has dementia, daughter has full time job, but does not want to place mom

• 5 days of day center attendance, bridge services in AM and PM when needed

• Transportation to and from center

• Bi-annual physical, all medications

• Social services, care coordination

• Respite care if needed

• Other services as needed (approved by IDT)

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PACE benefits, cont.

• 55 year old female, multiple comorbidities

• NH eligible for community programs by state due to comorbid conditions

• Utilized emergency services 1-3 times/month prior to enrollment (functioned as primary care)

• Reduction in utilization and increase in self report quality of life

Nursing Home Level of Care• Set by individual states

• Eligibility for PACE is same as for other Community Based Services (i.e. NH eligible for community programs)

• Varies widely—usually based on deficiencies in Activity of Daily Living (ADL)

Example of state requirements for PACE:

• DE = 1 ADL deficiency

• NJ = 3 ADL deficiency

• Participants can look very different from state to state

PACE Enrollees Snapshot

Mean Age 77.5

Gender 73% women

Average Number of Basic ADL Deficits

3.5

Cognitive Impairment 63%

Average Life Expectancy 2.2 years

Dually Eligible 90%

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The PACE Interdisciplinary Team (IDT)• The IDT is a CMS mandated hallmark of PACE programs• Includes:• RN*

• MD/NP*

• HCC*

• Social Worker*

• PT*

• OT*

• RT*

• Dietician*

• Day Center Manager

• Transportation

• Center Director * VOTING MEMBERS OF IDT Source: CMS 2011

The PACE IDT, cont.

• All care for participants is decided by the IDT• No member makes unilateral decision

• The IDT meets daily to discuss pertinent participant issues

• All interventions are included in an Interdisciplinary Plan of Care

• IDT updates the plan of care at minimum every 6 months

• When the IDT is split in opinion there is a vote to decide the direction of care

• All actions of the IDT are based on participant assessment and overreaching goals set by the care plan

Specialty Care

Medication

Supplies

DME

Transportation

Meals

Personal Care

Subacute Care

Hospital Care

• The Interdisciplinary Team (IDT), with the participant and caregiver, develop an individualized plan of care (POC) based on data from the IDT assessment and participant and family goals

• The POC is updated at six months and on an as needed basis

• Most care plans include care at the PACE Center and in the home

• Most participants attend the PACE Center 2 – 3 times each week

• Participants must agree to receive all services and medications through the PACE provider network (exceptions for emergency and urgent care)

• Some PACE Organizations allow continued visits with prior PCP

Interdisciplinary Team

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A LIFE Plan of Care

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PACE Care PlanRunning head: THEORISTS 1

Excerpt from Sample PACE Participant Care plan

Participant has

unstageable pressure

wound on R residual limb

preventing prosthetic use

3 x 3 cm wound with

eschar center unable to

stage at assessment

IDT Need/Str

Participant will demonstrate wound healing

Goal 10/21/15

Consult with wound/vascular

specialist as needed PCP, RN Intrv 10/21/15

Wound care as prescribed

HHRN, PCP

Intrv 10/21/15

Participant to demonstrate functional transfers without bearing weight on residual

limb

Goal 10/21/15

OT to provide education and training

OT Intrv 10/21/15

Participant will remain safe in home environment

Goal 10/21/15

Assess for home care needs

once enrolled

HCC,

HHRN Intrv 10/21/15

Nurses in PACE

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Nurses in PACE

• Nurses can hold many roles within a PACE organization

• Director of Nursing

• Health Center/Clinic roles

• Home Health roles

• Case Management roles

• Quality/Risk Management RN

• Infection Control Nurses

• WOCN

• APNs (Nurse Practitioners)

• Unlimited opportunities based on program need and size

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Nurses in PACE, cont.

• Nurses are a regulatory member of the PACE IDT• Beyond that, CMS is limited in what it says is the role of

the nurse in PACE

• Literature reveals that the role of nurses in PACE programs is understudied

• Based on experience of presenter, nurses in different roles are integral to function of PACE programs, but nursing in PACE setting nearly absent in the literature

Case Study

• 76 year old male, no formal caregiver, wife's sister assumed responsibility for him after wife passed

• NH eligible (for community and placement), but is he appropriate?

• Has informal caregiver/home

• Benefits from PACE services and is safe in environment

• 5 day center attendance, medical needs met, sees nurses daily, in home services and respite as needed

Case study, cont.

• Prior to enrollment

• ED visits/PAH:

- 2013—7 ER visits/ 3 admissions

- 2014—Jan-July 31 (prior to enrollment)—6 ER visits /

3 admissions

• After enrollment

• ED visits/hospitalizations:

- 2014—Aug-Dec—3 ER with 1 admission (learning period)

- 2015 to date—2 ER visits with 1 admission (not PAH)

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PACE Outcomes and Benefits

©2015 Trinity Health PACE - Livonia, Mich. 31

Why PACE??

• PACE participants and caregivers report:

• Improved quality of life

• Stable or improved functional outcomes

• Decreased caregiver stress

• Decreased likelihood of nursing home placement

• Increased likelihood that end of life wishes are followed

Sources: Segelman, et al., 2015, Weiland, et al., 2010, Schamp & Tenkku, 2006.

Why PACE?

• Research indicates:

• Decrease in Medicare dollars spent among peer groups

• Increase or stabilization of function among PACE enrollees

• Decrease in hospitalization rates

• Decrease in nursing home placement rates

• Increase in not only quality, but quantity of life (PACE participants lived 1.3 years longer than peers)

Source: Segelman, et al., 2014, NPA, 2011, Beauchamp et al., 2008, Chatterji, et al., 1998

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Cost Comparison

• Several studies validate:

• Decreased hospitalization rates

• Decreased utilization of nursing homes

• Decrease in Medicare spending vs. peer groups

• All of this in the frailest of the elderly who traditionally utilize Medicare dollars $$

Source: Segelman, et al., 2014, NPA, 2011, Beauchamp et al., 2008, Chatterji, et al., 1998

Hospitalization Rates

574

719

962

538

Duals - All Duals - NH Duals - HCBS PACE

Hospital Discharges Per 1000/Year

44%

Source: Temkin-Greener 2011; Walsh 2010

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Hospitalization Utilization

4,076

5,247

6,447

3,024

Duals - All Duals - NH Duals - HCBS PACE

Hospital Days Per 1000/Year (DPK)

53%

Sources: Temkin-Greener 2011; Walsh 2010; National PACE Association Cross-site data CY 2014

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PACE Nursing Home Placement

100%

7%

NH Certified NH Placement

Source: National PACE Association data

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Trinity Health PACE Quality Metrics for FY16

Metric Definition

Total Fall Rate Number of Falls X 1,000 / Participant Days

Falls with Major Injury Falls with Major Injury or Death X 1,000/Participant days

Pressure Ulcer rateTotal Participants With Stage III, IV or unstageable PUs X 1,000 / Monthly Census

UTI Rate Total UTI's X 1,000/participant days

Percent Participants Immunized for FLU (October - May Only)Number of Participants Immunized / Total Participants for Month

Percent Participants Immunized for PneumococcalNumber of Participants Immunized / Total Participants for Month

Acute Admissions Rate Total Inpatient Admissions X 1,000/Total Participant Days

All Cause Hospital Readmissions Within 30 Days

Percent of hospital discharges with a readmission within 30 days of discharge date – all cause, planned or unplanned, incPsych

SNF Rate Total SNF Days X 1,000/Total Participant Days

Participation Satisfaction - Overall SatisfactionPercent "Excellent" on "How would you rate your overall satisfaction with this center?"

Participation Satisfaction - Recommendation to OthersPercent "Excellent" on "What is your recommendation of this center to others?"

Employee Engagement Overall Percent favorable -" Overall I am a satisfied colleague"

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Local PO’s also track additional metrics based on their QAPI plan

• PACE is a viable alternative for frail elderly who wish to remain living in the community

• PACE programs are successful in reducing unnecessary utilization

• PACE programs offer a unique practice setting for nurses

• PACE programs offer traditional and non-traditional opportunities for nurses

Summary and Questions

Please reach out with questions or for more information:

MCunningham@che-east.org

Carrie.haysmcelroy@trinity-health.org

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References• Beauchamp, J., Cheh, V., Schmitz, R., Kemper, P., &. Hall, J. (2008). The Effect of the

Program of All-Inclusive Care for the Elderly (PACE) on Quality. Retrieved from http://www.cms.gov/Research-Statistics- Data-and-Systems/Statistics-Trends-and-

Reports/Reports/downloads/Beauchamp_2008.pdf

• Centers for Medicare and Medicaid. (2011). Chapter 8. IDT, Assessment & Care Planning. Retrieved from http://cms.gov/Regulations-and- Guidance/Guidance /Manuals/Downloads/ pace111c08.pdf

• Centers for Medicare and Medicaid. (2008). Quick Facts about Programs of All-Inclusive Care for the Elderly. Retrieved from https://www.medicare.gov/Pubs/pdf/11341.pdf

• Chatterji, P., Burstein, N., Kidder, D., and White, A. (1998). Evaluation of the program of all-inclusive care for the elderly (PACE) demonstration: the impact of PACE on participant outcomes. Pace Impact Report. Retrieved from http://www.npaonline.org/website/download.asp?

id=1933&title=CMS:__Impact_of_PACE_on_Participant_Outcomes

• Fretwell, M. D., Old, J. S., Zwan, K., & Simhadri, K. (March 06, 2015). The Elderhaus Program of All-inclusive Care for the Elderly in North Carolina: Improving Functional Outcomes and Reducing Cost of Care: Preliminary Data. Journal of the American Geriatrics Society, 63, 3, 578- 583.

References• National Pace Association. (2015). Pace in the states. Retrieved from

http://www.npaonline.org/website/download.asp?id=1741&title =PACE_in_the_States

• National Pace Association. (2011). NPA hospital utilization/readmissions analysis summary of results to date. Retrieved from http://www.npaonline.org/website/download.asp ?id=4463 &title=NPA_Hospitalization/Readmission_Analysis

• Saint Francis Healthcare. (2015). PACE services. Retrieved from http://saintfrancishealthcare.org/

• Schamp, R. and Tenkku, L. (2006). Managed death in a PACE: Pathways in present and advance directives. Journal of American Medical Directors Association, 7, 339-344.doi:

10.1016/j.jamda,2006.01.022

• Segelman, M., Szydlowski, J., Kinosian, B., McNabney, M., Raziano, D., Eng, C., van Reenen, C., and Temkin-Greener, H. (2014). Hospitalizations in the program of all-inclusive care for the

elderly. Journal of the American Geriatrics Society, 62, 320-324.

• Wieland, D., Kinosian, B., Stallard, E., and Boland, R. (2012). Does Medicaid pay more to a program of all-inclusive care for the elderly (PACE) than fee-for-service long-term care? Journal of Gerontology: MEDICAL SCINECES, 68(1), 47-55. Doi:

10.1093/Gerona/gls137