Linda Gibson, President & CEO

Linda Gibson, President & CEO

Topics Community-based palliative care the unfunded approach Partners in Palliative Care Pilot with Partners in Palliative Care Pilot with Partnership Health Plan of California (PHC) the funded approach

Why Start an Unfunded Palliative Care Program? To promote Hospice program growth and improve length of stay To fill care delivery gaps in the community To reach the Latino population A Warm hand-off for discharged Hospice patients To control the message about Hospice A new way to engage Physicians and other referral sources

Eligibility Progressive advanced illness and Significant and complex symptoms Multiple recent hospitalizations In need of advance care planning Uncertainly regarding goals of care In need of support in end-of-life decision making May be receiving curative therapy May be in a skilled nursing facility Would you be surprised if your patient died in the next year?

Care Delivery Model Services Staffing Setting Initial Assessment RN Home * Pain / symptom management Advance Care Planning / POLST RN PrimaryCare, Medical Director, RN Home Telephone Home Coordination of Care RN Home Telephone Monday Friday (8 a.m. 5 p.m.) Telephonic Support RN / Volunteer RN Telephone Care Management Plan RN Home Telephone Help with practical needs Volunteers Home Reimbursement: Fee-for-service, $60.00 / month & sliding fee * Home, Skill Nursing Facility, Board & Care, Assisted Living, Retirement

Other Considerations Need to be very clear about scope of services and frequency of visits: Monthly visits Weekly telephone calls Occasional social work and spiritual care consultation Focus is on education, coordination and consultation Use of volunteers helps to control costs and provides a richer patient experience RN case load = 45 50 patients Requires surprisingly little marketing and outreach

Lessons Learned Exceedingly well received in the community Physicians, families love the program Need to have a plan to move patients to Hospice when eligible Improves ability to keep discharged Hospice patients in the fold Allowing volunteers to stay with the patient during transitions from / to Hospice facilitates continuity Has helped Hospice LOS ROI improves every year

60 Transitions Palliative Care Average Daily Census Comparison 2011-2015 55 55 = August 2014 YTD 50 46 44 40 30 20 21 10 0 2011 2012 2013 2014 2015

Transitions Transfers to Hospice -MLOS MLOS Hospice 40 35 30 25 20 22 17 20 19 15 34 10 5 15 16 23 0 2011 2012 2013 2014

Transitions Transfers to Revenue 1400000 1200000 1000000 800000 600000 400000 1,084,626 1,290,976 200000 0 583,121 195,415 Expense - $206,218 2011 2012 2013 2014

Napa Valley Hospice & Adult Day Services Partnership Health Plan of California

Partnership HealthPlan of California Mission: To help our members, and the communities we serve, be healthy Membership: 540,000 in 14 counties Model: Not-for-profit, Community Organized Health System Primary Care: 77% at FQHC, RHC or Native Health Center

Offering and Honoring Choices TM Partnership HealthPlan s Initiative to promote Advance Care Planning and Palliative Care. 14 Projects Purpose: Ensure that our members and their families are knowledgeable about healthcare treatment options, empowered to define their treatment goals, and able to make informed choices about the interventions they prefer during the last years of life.

Offering and Honoring Choices TM Projects

PHC Palliative Care Pilot CHCF planning grant (2014) Working group of hospice agencies and palliative care physicians contributed to proposed plan PHC awarded CHCF implementation grant (2015) Four pilot sites selected: Resolution Care (Humboldt County) Napa Valley Hospice and Adult Day Services (Napa County) Hospice of Yolo (Yolo County) Interim HealthCare (Shasta County)

PHC Pilot Eligible Patients Life expectancy less than 2 years Advanced severity (when not decompensated ) Any of six diagnoses: Congestive Heart Failure COPD Cirrhosis Dementia Frailty Syndrome Stage IV Cancer

Partners in Palliative Care Service Model

Partners in Palliative Care: Payment Model Global Payment Per enrolled member, per month One rate if resident of SNF or if skilled nursing services not included Another rate if in-home nursing included Bonus Payments: Quality: Bonus per Quarter for Meeting Quality Metrics Shared Savings: Bonus per month if no Emergency Department visits or Hospitalizations during the month

Engaging the Health Plan A history of working together successfully Hospice Services CBAS services Lead agency for community ACP project Partner together to put on an annual palliative care educational conference Planning Partner, then Pilot for testing a palliative care benefit

What You Need From the Health Plan Mission alignment Mutual respect Common focus on quality Appreciation for importance of financial sustainability Collaborative approach Innovative practices willingness to try new approaches

What You Need From the Health Plan Access to data Provider lists Eligible members (frequent flyers) Cost data Flexibility In care model design and implementation In eligibility requirements

What You Need From the Health Plan Simplified enrollment and billing processes Limit data submission requirements PMPM works well (we think ) Promotional assistance Joint press releases Letters to providers announcing benefit

Evaluating Payment Models Must be financially sustainable for the provider: Costs of building a new program Financial modeling of assumptions Balancing risk and likelihood of success Importance of baseline financial stability

Contact Information Linda J. Gibson President & CEO Napa Valley Hospice & Adult Day Services lgibson@nvhads.org 707.285.9080

Ann Hablitzel, RN, BSN, MBA Hospice Care of California

Objectives You will learn to: Identify and speak to the priorities and challenges of payer sources Describe the core components of a Community based Palliative Program

Mission Statement for Palliative Program To advance, support and provide a Community based Palliative Care Program. We envision a seamless, less fragmented and more coordinated care system, that also addresses effective stewardship of resources.

Focus of Program Provide symptom management and emotional support to patient/family Assist with EOL discussions/decisions Promote a smooth transition to Hospice. Implement Palliative Care Program to a targeted population in order to reduce ER visits and inpatient hospitalizations Promote appropriate utilizations of resources to reduce unnecessary costs Promote transition to Hospice when appropriate Improve patient care

Program Goals To address physical, psychological, social, spiritual, practical expectations and needs To reduce or eliminate Emergency Room visits (especially for pain/symptom management) and total care costs To reduce or eliminate (unplanned) hospital admission and/or readmission To promote a seamless transition from curative to Palliative to Hospice for patients and their families. To address goals of care and advance care planning To assess the individual primary care physicians and subspecialists preferences in communicating to members of the team To assist family members emotional adjustments to the changing role in relation to the patient and within the family system through support and education

Structure and Process Identification of patients who would benefit from Palliative Care Program Develop Criteria for evaluation and admission Referral process Fax sheet MD order Authorization process Letter of explanation - to family (English and Spanish) -to PCP

Basic Disease Process Criteria Cancer (metastatic/recurrent) Advanced COPD Stroke (with decreased function by at least 50%) End-stage Renal Disease Advanced Cardiac Disease i.e.; CHF, Severe CAD, CM (LVEF less than 25%) Frail Elderly with Multiple Diagnosis Other Life-limiting Illness

Criteria Concomitant Disease Process Liver Disease Moderate Renal Disease Moderate COPD Moderate CHF Other Condition Complicating Care Other Criteria to consider in Screening Team/patient/family needs help with complex decision making and determination of goals of care Patient has frequent visit to emergency department (greater than 1 time a month for same diagnosis) Patient has more than 1 hospital admission for the same diagnosis in the last 30 days

Interdisciplinary Team Based Care Communication Provide purpose and explanation of Palliative Program Provide purpose and explanation of Palliative Program to Clinical Team focus on communication, authorization process and utilization of resources

Evidence Based Outcome Data Data Collected Demonstrating Cost Avoidance or Improved Resource Utilization Measuring Quality Pain and symptom management Patient/family satisfaction Advanced care planning Improved utilization outcomes Hospitalizations Hospital readmission rate Emergency room visits

Summary & Lessons Learned California is a highly capitated and competitive market with diverse population urban and rural Culture Economic affluent and extreme poverty Healthcare Payer sources (IPA s, Medical Groups, Hospitals Cancer Center Insurance Plans) Medicare Advantage Plans Full risk or shared risk Needs Assessment of Payer Source Identify their goals and outcomes Reduction of costs with high quality patient care

Thank you

Jeff Hammond Sea Crest Home Health Services Inc. November 9&10 2015

MCCM Details The model is designed to: Increase access to supportive care services provided by hospice; Improve quality of life and patient/family satisfaction; Inform new payment systems for the Medicare and Medicaid programs. Number of Participants: 141 California Participants: 4 Assisted HomeCare Inc. dba Assisted Hospice Care(Los Angeles, California) Assisted Home Hospice(Los Angeles, California) Sea Crest Hospice Services, Inc. (Orange County, California) CareChoices Hospice and Palliative Care Services, Inc. (Orange County, California) Hospice of Saddleback Valley(Orange County, California) 5 year pilot The model will be phased in over 2 years. Participating hospices will be randomly assigned to Phase 1 or Phase 2. Services will begin starting January 1, 2016 for the first phase of participating hospices and in January 2018 for the remaining participating hospices. Participating hospices will receive payment under the model through the standard Medicare claims process

How does MCCM operate? The hospices will be paid a $400 per beneficiary per month (PBPM) fee for providing services under the model for 15 or more calendar days per month. If services are provided under the model for fewer than 15 calendar days per month during the first month that the beneficiary is in the model, the hospices will be paid $200 PBPM. As the beneficiary is not electing the Medicare hospice benefit, hospices participating in this model will not receive the Medicare Hospice Benefit per diem rates Services provided under the model are not subject to a copay

Target Population The target population for the Medicare Care Choices Model is: Medicare beneficiaries who are eligible for the Medicare Hospice Benefit and dually eligible beneficiaries who are enrolled in traditional Medicare and eligible for the Medicaid hospice benefit. Medicare and dually eligible beneficiaries must not have elected the Medicare Hospice Benefit (or the Medicaid hospice benefit) within the last 30 days prior to participating in the model and satisfy all the eligibility criteria listed in the Request for Applications. The model provides Medicare beneficiaries who qualify for coverage under the Medicare hospice benefit and dually eligible beneficiaries who qualify for the Medicaid hospice benefit the option to elect to receive supportive care services typically provided by hospice while continuing to receive curative services Participation is limited to beneficiaries with: advanced cancers chronic obstructive pulmonary disease congestive heart failure human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS).

The Sea Crest Care Pathways Program Goals Promote the highest quality of life by controlling symptoms such as pain, shortness of breath, nausea, vomiting, fatigue and anxiety. Provide psychological, spiritual and relational support for patients, families and staff. Facilitate communication about the illness process and options for care. Educate community hospitals, physicians, skilled nursing facilities, families, patients, and our staff about palliative care practices and philosophies. Conduct research and promote community efforts to continuously improve the quality of care for people with serious and life-threatening illnesses. Program advantages and benefits: Improved quality of life that allows patients the time to live every moment. Intensive symptom and comfort management (alleviate pain, fatigue, anxiety, nausea, loss of appetite, sleeplessness, depression and other complex medical care issues). 24-hour phone access to RN Program Managers and/or triage nurses that coordinate medical, psychological, and related support and communication services. Trusted care coordination for intelligently navigating the health care system. Education regarding all care options. Guidance regarding complex treatment, emergency room admission or re-hospitalization choices. Physical, emotional and spiritual support to encourage complete well-being throughout the care continuum.

Anastasia Dodson, Associate Director Department of Health Care Services

Medi-Cal Palliative Care Program Development SB 1004 (Hernandez) Enacted in 2014 DHCS has been consulting with palliative care experts and stakeholders: Develop a shared understanding of palliative care Review data findings Consider performance measures Review October 2, 2015 Medi-Cal Palliative Care Paper

DHCS Goals for Medi-Cal Palliative Care 1. Establish standards and provide technical assistance for Medi-Cal managed care plans to ensure delivery of palliative care services. 2. Establish guidance on the medical conditions and prognoses that render a [Medi-Cal] beneficiary eligible for the palliative care services. 3. Develop a Medi-Cal palliative care policy that, to the extent practicable, is cost-neutral to the General Fund on an ongoing basis. 4. Define Medi-Cal palliative care services, to include but are not limited to those types of services that are available through the Medi-Cal hospice benefit. 5. Provide access to both hospice-type services and curative care at the same time, to the extent the services are not duplicative, for beneficiaries eligible for Medi-Cal palliative care.

Medi-CalPalliativeCareScope Medi-Cal palliative care will use specific definitions of eligible conditions, services, and providers Specificity is needed: To meet the requirements of SB 1004 Long- term success is more likely through an incremental approach

Delivery System and Dual-Eligible Considerations Initial focus on managed care; further analysis needed for fee-for-service Medi-Cal Initial focus on Medi-Cal only beneficiaries (not dually eligible for Medicare) Considering policy options for beneficiaries in HCBS waiver programs, nursing facilities, and potentially Cal Medi-Connect.

Proposed EligibleCondition for Medi-Cal Palliative Care Late-Stage/High Grade Cancer with significant functional decline or limitations Should DHCS provide more specific standardized clinical criteria on this condition? Allow Medi-Cal Managed Care Organizations (MCO) to use one of several existing screening protocols?

AdditionalConditions Existing palliative care programs generally include additional conditions, such as advanced Congestive Heart Failure or end-stage pulmonary disease. Managed care plans that currently (or in future) authorize palliative care consults and services for patients with other medical conditions may continue to do so.

ProposedPalliativeCareServices When reasonable and necessary for the palliation or management of a qualified serious illness and related conditions, and when provided by qualified personnel: Hospice-Type Services (DHCS All-Plan Letter 13-014) Additional Services: Palliative Care Consultation, Advance Care Planning Care Coordination, Assessment, Interdisciplinary care team, Care Plan * Curative Care *

ProviderQualifications Consider full range of inpatient, outpatient, community-based providers. DHCS is considering options: Palliative Care Training Palliative Care Certification, Accreditation Health Plan Credentialing Add Palliative Care component to existing provider qualifications

PerformanceMeasures DHCS developing performance measures DHCS considering linking payment to performance DHCS considering linking payment to performance measures, particularly in fee-for-service

Questions and Contact Info DHCS Palliative Care Website: http://www.dhcs.ca.gov/provgo vpart/pages/palliative- Care- and-sb-1004.aspx Contact: SB1004@dhcs.ca.gov