October 16, 2017 PACE INNOVATION THE NEW YORK WAY NATIONAL PACE ASSOCIATION ANNUAL MEETING OCTOBER 16, 2017 PANEL PRESENTATION AND DISCUSSION Jade Gong, RN, MBA Principal Jade Gong & Associates Patrick Cucinelli Program Manager NYS Department of Health PACE Expansion without Innovation Act NY State Perspectives Henriette Kole VP, PACE ArchCare Senior LIFE ArchCare Strategy for PACE Expansion 2 @ JadeGongRN 1
October 16, 2017 PACE INNOVATION: IMPLEMENTATION TIMELINE??? 3 J une 2015 N ovember 2015 M arch 2016 A ugust 2016 D ecember 2016 J uly 2017 S eptember 2017 For Profit PACE allowed PACE Innovation Act Passes InnovAge for profit conversion approved CMS PACE Proposed Regulation offers additional flexibilities CMS issues RFI on expansion populations CMS seeks additional comment on payment issues CMS issues RFI on New Directions for CMMI SEEKING FLEXIBILITIES TO SERVE MEDICARE-ONLY BENEFICIARIES REGULATORY AND LEGISLATIVE OPTIONS BEING PURSUED Flexible Premiums Choice of Part D Plan Two Way Option to Serve Medicareonly beneficiaries Consumers paying for care need rates based upon needs as current Medicaid rates are not adjusted for needs Consumers paying for care should have a choice of Part D plan at lower premium PACE Programs operating in states that do not allow Medicaid should be able to establish a contract to serve Medicare-only beneficiaries Sources: NPA Fact Sheet and Altarum Paper on Barriers and Possible Solutions, 2017 4 @ JadeGongRN 2
October 16, 2017 PACE INNOVATION THE REALITY WHAT SHOULD A PACE PROGRAM DO? Continued excitement about PACE innovation but it is moving along slowly with only the physically disabled population over age 21 under active development by CMS Long awaited proposed regulation is not yet final Some additional non profit to for profit conversions Disruptors with new business models to serve the high cost/high need populations continue to emerge such as Landmark and Principium 5 PACE INNOVATION THE DREAM SERVING NEW POPULATIONS WITH A MORE FLEXIBLE MODEL Medically Complex but not yet NH eligible Under Age 55 Medicare-Only Population Flexibility in IDT team composition Flexibility with day center requirements 6 @ JadeGongRN 3
October 16, 2017 MANAGED CARE GROWTH CONTINUES IN NY AND ACROSS THE COUNTRY; DISRUPTORS ALSO EMERGING Traditional MLTSS Plans Financial Alignment Demonstration Plans Non Traditional Independent at Home Demonstration 7 PACE IS A MODEL THAT DELIVERS Source: Effective Care for High-Need Patients. National Academy of Medicine, Accessed September 27, 2017. https://nam.edu/effective-care-for-high-need-patients/ 8 @ JadeGongRN 4
October 16, 2017 GROWING TRADITIONAL PACE WITHOUT THE INNOVATION ACT 9 PACE INNOVATION THE NEW YORK WAY Strategy Create partnerships to drive enrollment growth Serve specialty populations who are PACE eligible Offer housing and social supports Description Partner with aligned organizations to turn ADHCs into alternate sites Use DD Demonstration to create specialty programs and community awareness Seek Assisted Living Demonstration 10 Use existing waivers Use PCP waiver to grow referrals from targeted physicians @ JadeGongRN 5
October 16, 2017 11 Presented by Patrick Cucinelli, MBA, LNHA, EMT @ JadeGongRN 6
October 16, 2017 13 In New York, there are nine PACE Plans operating a total of 18 centers for Medicare, Medicaid and private pay enrollees. 14 NY s First PACE, Comprehensive Care Management (now known as CenterLight Health Care) began operations in the Bronx, and has since grown to become one of the largest PACE Organizations in the nation. @ JadeGongRN 7
October 16, 2017 15 16 @ JadeGongRN 8
October 16, 2017 17 PACE Uniquely Qualified to Manage the Dual Eligible The Dual Eligible Population: o Over 750,000 Dually-Eligible Individuals Enrolled in Medicaid Program o 51 Percent Income Below Federal Poverty Level o Generally Poorer Health and More Complex Co-Morbidities o Approximately 20 Percent are Institutionalized o 16 Percent of Medicare Population, Accounting for 27 Percent of Medicare Spending o 15 Percent of Medicaid Population, Accounting for 45 Percent of Medicaid Spending Source: Medicare Payment Advisory Commission Data Book 18 Medicaid Redesign Team (MRT) New York has established a new Medicaid 1115 waiver that will allow the full depth and breadth of the MRT s recommendations to be implemented. The goals of this waiver include: o Allowing New York to lower health care costs, improve patient outcomes and reduce health disparities by successfully implementing and maintaining the wide array of critical reforms approved by the MRT; o Ending the state s Medicaid fee-for-service system and replacing it with a comprehensive, high-quality and integrated care management system that will lower costs and improve health outcomes; and o Implementing the program changes called for in the Affordable Care Act (ACA) quickly and efficiently. @ JadeGongRN 9
October 16, 2017 19 Uniform Assessment System for New York (UAS-NY) The UAS-NY is a web-based record of individuals involved in the State's Medicaid program. The record includes the individual's demographic information, residential and service delivery addresses, assessment information, and assessment outcome information, and applies to all managed care and FFS community-based provider types. The UAS-NY is completed as part of the admissions, initial care plan and periodic reassessments processes. The UAS-NY is critical for: Establishing a score of 5 or above, indicating a Nursing Home Level of Care (NHLOC); and determining the need for the Community-Based Long Term Care services of the plan for more than 120 days. Eligible individuals who are enrolled in a facility or any HCBS waiver program may not be accepted for enrollment unless they can be discharged from the facility or disenrolled from the waiver program. 20 Conflict-Free Evaluation and Enrollment Center (CFEEC) In accordance with our 1115 waiver, NY was required to develop an independent and conflict-free evaluation process, including the NHLOC and the need for Community- Based Long Term Care (CBLTC). Effective October 2014, NY implemented CFEEC for individuals seeking Community- Based Long Term Care (CBLTC) services for more than 120 days. New applicants seeking enrollment in PACE or any of NYS s MLTC products, applicants must be evaluated by CFEEC instead of going directly to plans for enrollment. CFEEC uses the UAS-NY to conduct evaluations and establish eligibility. MLTCs continue to be responsible for completing their own assessments to determine the plan of care. @ JadeGongRN 10
October 16, 2017 21 Mandatory Enrollment: 1115 waiver requires dual eligibles over age 21 to enroll in MLTC when seeking CBLTC services. The NYS enrollment broker, NY Medicaid Choice, provides guidance on plan options. o PACE is included in the list of mandatory MLTC options. o In September 2012, with CMS approval, NYS began mandatory enrollment of the FFS home care population. o Individuals not selecting a plan within 60 days were auto-assigned into a partially capitated plan. 22 Health Information Technology (HIT): New York envisions a health care delivery system in which every provider has access to the vital patient information they need to effectively provide and manage care. New York has made progress in this area, but additional investments will help ensure that by the end of the decade every New Yorker will benefit from a statewide, interoperable EHR system. For more information: NY Medicaid Electronic Health Records (EHR) Incentive Program and Office of Health Information Technology Transformation. @ JadeGongRN 11
October 16, 2017 23 NY Criteria Includes the Following CBLTC Requirements: Age 55 or older; Live in the service area of a PACE organization; Require a nursing home-level of care; Are able to live safely in the community with help from PACE; and In need of CBLTC for more than 120 days. Most importantly, everything the PACE does is geared towards the goal of allowing folks to stay in the community and avoid unnecessary hospitalizations and institutionalization; the ultimate mission of any comprehensive, community-based managed care program. 24 @ JadeGongRN 12
October 16, 2017 25 New Models & Innovation The Act On November 5 th, 2015, President Obama signed The Program of All-Inclusive Care for the Elderly Innovation Act (the Act) into law: o This measure authorizes the Secretary of Health and Human Services to waive applicable general and Medicaid requirements of PACE to conduct demonstration projects through the Center for Medicare and Medicaid Innovation (CMS Innovation Center). 26 New Models & Innovation State RFI In response to the authorization of the PACE Innovation Act, New York was out of the gate early last year with our own Request for Information (PACE Model Expansion RFI). o We received enthusiastic responses from a variety of stakeholders, offering key recommendations. @ JadeGongRN 13
October 16, 2017 27 New Models & Innovation State RFI New York PACE organizations have already received approval for community physician and nurse practitioner waivers. The ArchCare PACE Pilot Project is now serving individuals with intellectual/developmental disabilities (I/DD). New York was out of the gate early last year with our own Request for Information (PACE Model Expansion RFI) 28 New Models & Innovation State RFI A total of 37 responses were received from stakeholders across New York State including managed long term care plans (MLTC), current PACE programs and providers, and others considering implementing a PACE plan. The majority of respondent organizations are located in the NYC Metro area; however, respondents represent all NYS DOH regions. @ JadeGongRN 14
October 16, 2017 29 New Models & Innovation Expanded Interest While most respondents do not currently operate a PACE program or provide services to a PACE program, the majority of respondents (65 percent) indicated organizational interest in implementing a PACE program in the future. o The PACE Innovations Act is providing an incentive for providers and plans to consider changes to their service package. o About half of respondents, 51 percent, or 19 out of 37, are considering changes to their service package as a result of the Act. 30 New Models & Innovation Service Changes Incorporating telehealth for rural environments Special programming for Parkinson s disease, Alzheimer s disease and behavioral disorders, and the hearing impaired Changes to the Interdisciplinary Team (IDT) Providing services in other community settings and offering a program that does not have a day center requirement A program that serves both participant and caregiver Treatment models for managing acute and chronic behavioral health conditions for persons with disabilities and Traumatic Brain Injuries (TBI) @ JadeGongRN 15
October 16, 2017 31 New Models & Innovation Population Changes The populations for which respondents are considering adding programs or services include: o Individuals under 55 years old with disabilities; o Individuals older than 55, but not yet nursing home eligible; and o Other populations including individuals with Intellectual or Developmental Disabilities (I/DD). 32 New Models & Innovation Service Areas Respondents report considering changes to the geographic area they serve. Interested in expanding to nearby counties: o The ability to base service area on geographic proximity of participants to the service center instead of being confined to county lines. o Suggestion that service area should align with existing community definitions so that an entire community can be served by a PACE program. @ JadeGongRN 16
October 16, 2017 33 New Models & Innovation Issues raised by survey respondents as potential barriers: Regulatory Lack of Understanding/Awareness Rate Setting Methodology Lack of Capital Staffing Issues 34 New Models & Innovation The PACE Value Proposition Interdisciplinary Team and Coordinated Care Management (suggestion to include a clinical pharmacist) Coordinated Care Management Effective communication via EMR Coordination of Medicare and Medicaid benefits and reimbursement for dual eligible individuals Enhanced socialization and community support @ JadeGongRN 17
October 16, 2017 35 New Models & Innovation Outreach Challenges Move beyond the perception that PACE is for elderly people who live alone in their own home and who want a day program with other seniors Ads for PACE programs that focus on diversity and inclusion of different populations More multi-lingual and adapted communication Lack of understanding of the PACE model by healthcare providers as it may be viewed as an HMO 36 New Models & Innovation Rural Expansion New York s rural areas can be very remote and inaccessible. Geography, transportation, poor weather conditions, and rural isolation can be barriers to PACE model expansion. Allowing the use of telehealth for services could alleviate this issue, as would amending regulations to allow for PACE without walls. Lastly, a lack of appropriate housing availability for PACE members was cited as a significant barrier for PACE program expansion. @ JadeGongRN 18
October 16, 2017 37 New Models & Innovation Housing Housing is the platform by which HCBS services can be adequately delivered. A lack of appropriate housing availability for PACE members may be barrier for PACE program expansion. o As a potential solution organizations are seeking to develop innovative partnerships. 38 New Models & Innovation PACE and ALP NY has an extensive Assisted Living Program (ALP) that combines a Medicaid component for enhanced ADL support with a Social Security component for room and board. o The ALP can be an alternative for individuals who need supportive medical services, but do not need to be in a nursing home. o Two of our PACE plans have submitted demonstration proposals designed to test how ALP and PACE can be combined. @ JadeGongRN 19
October 16, 2017 39 New Models & Innovation PACE and ALP Issues to be resolved in combining the two programs include: o Ensuring there is no duplication of services; o Is the arrangement financially viable for both parties?; o Ensuring that all state and federal regulatory requirements are met; and o Ensuring participant/resident rights. For both proposed demos, the ALP is under the same umbrella organization as the PACE. 40 New Models & Innovation - Ideas State RFI Responses: o Expanding the eligibility criteria for covered populations; o Integrating PACE with housing supports; o Innovative models that provide alternatives to Center-based services; o Expansion of rural-based PACE; o A larger role for telehealth and emerging technologies; o Community outreach and increasing the awareness of PACE; o Expanding partnerships with other providers and community organizations; and o Streamlining and greater flexibility in the IDT process. @ JadeGongRN 20
October 16, 2017 41 CMS RFI: CMS RFI Part 1 Person Centered Community Care (P3C) - a five-year PACE-like model test for individuals dually eligible for Medicare and Medicaid, age 21 and older, with disabilities that impair their mobility and who are assessed as requiring a nursing home level of care and meet other eligibility criteria. CMS RFI Part 2 Open-ended - CMS is seeking information on additional specific populations whose health outcomes could benefit from enrollment in PACE-like models, and how the PACE model of care could be adapted to better serve the needs of these populations and the currently eligible population. 42 CMS RFI: In general NYS is supportive of measures to achieve greater operational flexibility, eliminate redundant provisions and outdated information, and codify existing practices, with the goal of encouraging innovations in PACE. @ JadeGongRN 21
October 16, 2017 43 CMS RFI: Regarding the PC3 Model, we believe that the best strategy is to work within the framework of the traditional PACE model, without the necessity of introducing a separate and distinct version of PACE. 44 CMS RFI: There needs to be an enhanced role for telehealth and other emerging technologies as the potential benefit for this population would be significant. Non-Center based options are important and the Department supports increased flexibility in allowing for contracting with medical and clinical providers/services that traditionally would not be considered part of a PACE network or Center services, but would be critical in supporting new populations. o This flexibility should also include personal care and support services that are not traditionally found in PACE. @ JadeGongRN 22
October 16, 2017 45 General Recommendations to CMS: o Expanding the eligibility criteria for covered populations; o Integrating PACE with housing supports; o Innovative models that provide alternatives to Center-based services; o Expansion of rural-based PACE; o A larger role for telehealth and emerging technologies; o Community outreach and increasing the awareness of PACE; o Keeping options simple and understandable for consumers; o Expanding partnerships with other providers and community organizations; o Streamlining and greater flexibility in the IDT process; and o The expanded use of community PCPs. 46 Conclusion PACE in New York has proven itself an effective and successful model of person-centered managed care that is financially viable and supports global reform goals such as coordinating care across payer categories and providing care in community settings. Building on our record of success, we believe PACE is now set to evolve and expand even further. Innovative approaches to the delivery of care and services has been a hallmark of PACE from its inception, and this Department is eager to support the ongoing innovations. @ JadeGongRN 23
October 16, 2017 THANK YOU Patrick Cucinelli, MBA, LNHA, EMT Program Manager New York State Department of Health Office of Health Insurance Programs One Commerce Plaza Rm. 1605 Albany, NY 12210 518-474-6934 Patrick.Cucinelli@health.ny.gov Enjoy Boston! Henriette Kole Vice President ArchCare Senior Life @ JadeGongRN 24
October 16, 2017 ArchCare, Ever Evolving Focus ArchCare cares for people of all ages and faiths where they are most comfortable and best able to receive it at home, in the community and in nursing homes. Mission The mission of ArchCare, the continuing care community of the Archdiocese of New York, is to foster and provide faith based holistic care to frail and vulnerable people unable to fully care for themselves. Through shared commitments, ArchCare seeks to improve the quality of the lives of those individuals and their families. Home and Community Based Care Facility Based Care Additional PACE Highlights Opening of new Alternate Care Sites and Centers Connecting TimeBank Volunteers with PACE Supported by Shared Investments in IT, EMR, Care Coordination and Administration (HR, MARCOM, etc.) 49 ArchCare Service Area All Programs Sullivan Ulster Dutchess ArchCare Limited Service Area ArchCare/Dioceses of NY Service Area Orange Putnam Westchester Rockland Bronx Nassau Manhattan Queens Kings Staten Island Suffolk 50 @ JadeGongRN 25
October 16, 2017 ArchCare 2020 Key Indicators 2020 vs. 2017 Active Parish Partnerships Archdiocese Counties Served Service Recipients at Home Revenues from Shared Savings Technology Driven Care ArchCare Margin 51 Private Pay Mix in Services Portfolio 51 ArchCare Senior Life: History and Growth Our History and Growth to Date 2009 - First PACE center opened in Harlem 2012 Second center in the South Bronx 2-14 Third Center in Staten Island Three Alternate Care Sites (ACS) Completing DD/IDD grant from DOH Specialty programs for Deaf and Parkinson's' focused program Current census 650 and growing 52 @ JadeGongRN 26
October 16, 2017 ArchCare Senior Life - Service Area (Proposed) PACE Center Cabrini (Clinic-Westchester) (Proposed) ACS Washington Heights (Current) PACE Center Harlem Clinic (Current) ACS - Highbridge (Proposed) PACE Center Providence Rest (Current) PACE Center San Vincente de Paul (Current) ACS St. Marks Source: Internal Data (Current) PACE Center Carmel Richmond (Clinic-Staten Island) 53 ArchCare Senior Life Succeeding in a Crowded Marketplace 54 @ JadeGongRN 27
October 16, 2017 60. 0% 50. 0% 40. 0% 30. 0% 20. 0% 10. 0% 0.0 % Medicare Advantage Penetration NYC- Area Counties (July 2016) 60.0% 56.0% New York City Area Medicare Advantage Penetration - July 2016 50.0% 44.6% 40.0% 30.0% 41.7% 40.1% 38.3% 35.8% 37.5% 32.4% 24.9% 22.6% 21.8% 20.0% 19.0% 18.2% 17.5% 17.5% 16.8% 12.5% 10.0% 0.0% 2016 Medicare Advantage Penetration New York State Average National Average Source: 2016 CMS Data - http://tinyurl.com/hl7d6b8 (Accessed 8/5/2016) 55 Coming Soon: New PACE Center and ACS Locations 56 @ JadeGongRN 28
October 16, 2017 Partnerships, Partnerships, Partnerships ADHCs are not viable in the NYS managed care environment We are using existing flexibilities to convert AHDC to full PACE centers or ACSs We are using PCP waivers as needed to support community referrals 57 Specialty Programs: I/DD Demonstration DOH grant for the DD/IDD population who meet PACE eligibility criteria and their elderly caregivers, we currently have 5 families enrolled, parents and children Successfully integrated 55 DD clients into all three PACE centers Enhancements to the PACE Model of Care: - Hired specialty staff PT/OT/ST with previous experience with DD patients, behavioral interventionist, recreation therapists specific to DD/IDD needs, home care RN s and social workers - Extensive training in sensitivity, special medical needs, behavioral management, community integration New grant for Mental Health and DD population, opportunity by NYS DOH, based on Olmstead Act requirements, this grant is to place individuals in least restrictive environment and also provides housing options to make the moves happen 58 @ JadeGongRN 29
October 16, 2017 Specialty Programs: Program for Deaf Participants Interested PACE staff trained in American Sign language Located Licensed Home Care Agency with HHA s and RN s who are deaf and sign Allowed deaf participants to interact and attend the Wellness Centers (aka Day Health Center) Deaf ministry of Archdiocese of NY is a referral source and a unique connection to parishes to support the Pastor 59 Specialty Programs: Parkinson s Program All therapists trained in Big and Loud (LSVT) Participants with early to moderate Parkinson's Disease attend intensive 4 week program and home practice program Opportunity to market specialized neurological care All PACE staff trained in Matter of Balance ; NYC developed protocol for balance training for all participants to maintain balance and focus on fall risks Caregiver support groups available for families and participants 60 @ JadeGongRN 30
October 16, 2017 ALP Demonstration: Submitted to DOH Housing is the biggest need for PACE participants Currently, ALP residents cannot enroll in PACE ArchCare has submitted a demonstration proposal offer enrollment to the 59 resident of the St. Vincent DePaul ALP (co-located with the nursing home and the PACE Program) into the PACE program ALP staff will participate in the PACE IDT PCP waiver may be utilized if enrollees do not wish to change physicians Outcomes will be carefully monitored 61 Expanding PACE into the Northern Counties As part of its 2017 Strategic Plan, ArchCare committed to exploring the feasibility of expanding PACE into the northern counties of the Archdiocese of NY (Ulster, Orange, Dutchess, Sullivan, Putnam and Rockland) where there are significantly fewer services available to support frail elderly at home. Currently, there are no PACE programs operating in these counties. 62 @ JadeGongRN 31
October 16, 2017 Northern Counites have Fewer PACE Eligibles Creativity in service delivery will be needed in the Northern Counties PACE Eligible Density Age 55+ (Mid-Point) Eligible Area Density Newburgh 1,061 670.0 sq. mi. 1.6 Eligible /sq.mi. Poughkeepsie 359 160.4 sq. mi. 2.2 Eligible /sq.mi. Kingston 487 457.3 sq. mi. 1.1 Eligible /sq.mi. Westchester 2,714 430.5 sq. mi. 6.3 Eligible /sq.mi. Staten Island 1,634 58.4 sq. mi. 28.0 Eligible /sq.mi. Manhattan 9,662 22.8 sq. mi. 423.2 Eligible /sq.mi. Bronx 14,002 42.1 sq. mi. 332.6 Eligible /sq.mi. 63 Mobile Health Van in the Hudson Valley Exploring PACE Mobile Clinic and Telemonitoring Solutions 64 @ JadeGongRN 32
October 16, 2017 Age like a New Yorker Exposure to all the culture NYC has to offer, museum tours and classes, theater, parks, computer training Multi-cultural staff, native food, multi-lingual availability Inclusive of homeopathic and natural remedies 65 Concluding Thought I'm the one that's got to die when it's time for me to die, so let me live my life the way I want to. Jimi Hendrix 66 @ JadeGongRN 33
October 16, 2017 THANK YOU! Jade Gong 703-243-7391 Jade@jadegong.com @JadeGongRN Patrick Cucinelli 518-474-6934 Patrick.Cucinelli@health.ny.gov Henriette Kole 646-289-7700 hkole@arachcare.org 67 DISCUSSION AND QUESTIONS 68 @ JadeGongRN 34