Moving Forward with Transitional and Integrated Services: the Long-Term Services and Supports Providers’ Perspective

Moving Forward with Transitional and Integrated Services: The Long-Term Services and Supports Providers’ Perspective

Developed by the AAHSA Transitions and Integrated Services Taskforce Table of Contents Transitions and Integrated Services Taskforce Members Section I:

Maureen Hewitt (Chair) Steve Hess Introduction...... 2 Chief Executive Officer Immanuel Health Systems Total Long Term Care Omaha, Nebraska Taskforce and Workgroups...... 2 Denver, Colorado Jerry Kuyoth Charge...... 3 Dan Brady, Ph.D. Chief Operating Officer, Section II: Executive Director, Home and Health Division Community-Based Services National Church Residence Recommendations of the Transitions . Miami Jewish Health System Columbus, Ohio and Integrated Services Taskforce...... 3 Miami, Florida F. Michael Martin Section III: Rosemary Castillo Senior Vice-President Chief Executive Officer Riverside Health Systems Promising Models of Transitional and Integrated Care...... 4 Casa Bienvivir Newport News, Virginia El Paso, Texas Section IIIA: Rodney McBride Craig Connors Vice-President The Affordable Care Act...... 4 Executive Director, PACE Jon Knox Village Section IIIB: Riverside Health Systems Lee Summit, Missouri Newport News, Virginia Accountable Care Organizations...... 7 Jeff Petty Bev Dahan President & Chief Section IIIC: Total Long Term Care Executive Officer Denver, Colorado Wesley Enhanced Living Existing Transitional and Integrated Care Models...... 9 Southampton, Pennsylvania Gina DeBlassie Section IIID: Executive Director Pat Sprigg Total Community Care President & Chief Housing with Services...... 12 Albuquerque, New Mexico Executive Officer Section IIIE: Carol Woods Bob Edmondson Retirement Community Program of All-Inclusive Care for the Elderly...... 16 Chief Executive Officer Chapel Hill, North Carolina On Lok Section IIIF: San Francisco, California Cheryl Wilson Chief Executive Officer Continuing Care Retirement Communities (CCRCs)...... 18 Peter Fitzgerald St. Paul’s Senior Homes Volunteers of America and Services Section IIIG: Alexandria, Virginia San Diego, California Service Options Using Resources in . a Community Environment/Fee For Service...... 22

Bibliography...... 24 American Association of Homes and Services for the Aging 2519 Connecticut Avenue, NW. Washington, DC 20008-1520. www.aahsa.org

An AAHSA White Paper 1 Section I: Introduction from receiving the HCBS they need and deserve. In 2008, the most recent year for which figures are available, Today, people with chronic conditions must navigate a 393,000 people were on waiting lists for home and com- care system that is ill equipped to meet their needs. The munity-based services2. That number represents an human and economic toll is devastating. AAHSA members increase of more than 200,000 since 2002. are working on promising solutions to address the care needs of chronically ill people. The political will is needed Even a cursory review of the demographics of an aging to change clinical practices and policies in order to imple- American population and the prevalence of multiple ment evidence-based transitional and integrated care. chronic diseases should be enough to motivate us to implement transitional and integrated services for older At the most basic level, the care delivery system is frag- adults. Clearly, by sticking with the status quo, the mented nationwide, simply because each state has as much United States runs the risk of not being prepared to meet power as the federal government to determine reimburse- the complex needs of the future aging population. The ment for, and implementation of, long-term services and growth of this population cohort could have staggering supports. Acute care providers, primary care and specialty implications for providers and consumers of long-term care providers, and long-term services and support provid- services and supports. In July 2006, more than 37 million ers for years have provided services in their own care silos. Americans were 65 and older, a figure that represented This care vacuum leads to poor communication, mediocre a mere 12 percent of the nation’s population. By 2050, care, and high hospital re-admission rates. A recent New however, the over 65 population is projected to reach 86.7 England Journal of Medicine article reported that 20 per- million, or 21 percent of the population. The 85 and older cent of Medicare beneficiaries who were discharged from population, the population most likely to need long-term the hospital were readmitted within 30 days, and that 12 services and supports, is projected to increase from 4.2 1 percent of those re-admissions were preventable . It is million in 2000 to 8.9 million in 2030. during these transitional periods that older adults with chronic illnesses are most vulnerable. Medicare and Medicaid cost increases are not sustainable. The costliest 25 percent of Medicare beneficiaries account Within states, the lack of integration between the Medicare for 85 percent of cost, and 75 percent have at least one and Medicaid programs creates a dilemma for many older of seven chronic diseases. How will the nation meet the people. Often, these individuals do not have enough needs of this growing older population that is living lon- income to pay for home and community-based services ger and has more complex clinical needs? How will we (HCBS) out of their own pockets. Yet, many have too contain the skyrocketing care costs that lead to strained much income or too many assets to qualify for HCBS government budgets and assure consumer preferences under Medicaid. Other payment sources, such as Older to age in place? Members of AAHSA’s Transitions and American’s Act and Medicare funding provide only limit- Integrated Services Taskforce researched and discussed ed coverage for HCBS. Waiver programs that allow states these questions. to use Medicaid dollars for home and community-based skilled care often have long waiting lists and strict eligibility requirements that prevent many Medicaid beneficiaries

1 Testimony of Assistant Attorney General Thomas E. Perez Before the Senate HELP Committee June 22, 2 Testimony of Assistant Attorney General Thomas E. Perez Before the Senate HELP Committee June 2010. Online at: http://www.prnewswire.com/news-releases/testimony-of-assistant-attorney-general- 22, 2010. Online at: http://www.prnewswire.com/news-releases/testimony-of-assistant-attorney- thomas-e-perez-before-the-senate-committee-on-health-education-labor-and-pensions-on-the-ada- general-thomas-e-perez-before-the-senate-committee-on-health-education-labor-and-pensions-on- and-olmstead-enforcement-96910054.html the-ada-and-olmstead-enforcement-96910054.html

An AAHSA White Paper 2 Transitions and Integrated Services Taskforce Charge The Transitions and Integrated Services Taskforce was The AAHSA Transitions and convened by AAHSA leaders in 2010 and charged with Integrated Services Taskforce will: recommending to the AAHSA Board of Directors a plan • Help AAHSA understand the development of new that would improve care in transitional service settings, chronic care, transitional care, provider-based man- as well a plan to integrate all the services provided by aged care, and disease management models, and their care providers to assure quality and cost effectiveness of relationship to existing innovative models of long- care. term services and support that operate throughout the The taskforce focused on building programs with a com- continuum. prehensive focus rather than “boutique” programs that • Assist with the development of a state and federal have a narrow focus within our healthcare system. advocacy agenda that will facilitate the growth and sustainability of integrated programs that enable older Transitions and Integrated adults and persons with disabilities to age in place in a Services Taskforce Work Groups congregate housing setting. Members of the Transitions and Integrated Services Taskforce participated in four work groups that researched • Advise AAHSA about educational and other needs specific issues and formulated recommendations: of providers operating these programs, as well as members who want to expand into innovative care 1. The Housing with Services Work Group concentrated management services. on legislation and regulations that promote, or are barriers to, housing with services models, as well as • Provide input into AAHSA’s applied research agenda best practices in state government for housing with with an emphasis on developing pilot programs that services delivery. could be vehicles for members to be involved in future demonstration projects as part of healthcare reform. 2. The PACE Work Group examined how PACE uses an Develop a research agenda that includes evaluating effective integrated reimbursement system to assure existing programs for quality outcomes and cost con- quality of care during transitions from acute care to tainment. primary care to long term services and supports.

3. The CCRC Work Group focused on breaking down Section II: Recommendations the silos in care based on insurance coverage, specifi- The Transitions and Integrated Services Taskforce is com- cally for the non-Medicaid population, as older adults mitted to making sure that its final report becomes a age in place. blueprint for action to assure that AAHSA members are 4. The SOURCE/Care Management/Hospital-Based actively involved in the planning and implementation of System Work Group explored fee for service (FFS) the transitional and integrated service models addressed models that have conflict free case management that is in this report. To meet this goal, taskforce members and driven by quality outcomes. AAHSA staff will work together, and with other related organizations, to promote a philosophy of aging services At the beginning of its work, taskforce members worked that centers on long-term services and support providers together to write a charge, and desired outcomes in order being part of the solution for healthcare reform. Taskforce to guide its deliberations. members are encouraged to meet with members of their

An AAHSA White Paper 3 respective state associations to share the policy recom- 6. Providers with 2,000-plus participants should discuss/ mendations and best practices included in this document. research forming an accountable care organization AAHSA’s staff will develop materials that state affiliates with a local hospital to reduce re-admissions and can use to incorporate these recommendations into their improve chronic disease management. advocacy agendas. 7. Use the SOURCE program in Georgia as a template for the expansion of “patient navigator programs” Key Recommendations funded by the Affordable Care Act. 1. Provide information through conferences and webi- nars to AAHSA members on the existing transitions 8. Investigate how the CCRC model can be used effec- and integrated service programs, including the Care tively as a wellness and care coordination model under Transitions ProgramSM, Project BOOST, Guided Care, a capitated, integrated system to help older individuals Medicare Medical Home, Stanford Self Management, remain at a lower level of care as long as possible no bundling programs, housing with services models, matter what their income level is as they age in place. PACE programs, and other evidence-based models. Outcomes: AAHSA and its members will 2. Inform, and facilitate the efforts of, AAHSA members • Develop and participate in multi-state pilot projects who want to partner to apply for the transitions and for care management within a congregate setting. integrated services demonstrations in the Affordable Care Act. • Actively participate in transitional care and chronic care demonstration projects that will be implemented 3. AAHSA will be a catalyst for partnerships with uni- as a result of healthcare reform. versities, health systems/hospitals, primary care, and consumer groups. • Initiate legislation that will promote the expansion of chronic care, transitional care, managed care, and dis- 4. Advocate for a “housing with services” program in ease management models. Title III of the re-authorized Older American’s Act that would include collaboration between housing • Become fully engaged with the integration of housing providers and AAAs to improve care coordination for with service programs developed at the federal level by people living in affordable senior housing. designing the models and testing demonstrations.

5. Develop a close relationship with governmental and • Explore and implement models that increase commu- foundation funding sources that may be interested in nity and statewide engagement, promoting strategic funding additional research on: partnerships and pierce the silos that entrap Long- term Services and Supports. a. Transitions and integrated service models that have been developed by members. Section III: Promising Models of b. Additional incentive systems, such as pay for Transitional and Integrated Care performance and the use of PACE programs for a non-skilled and skilled population that require chronic disease management.

An AAHSA White Paper 4 Section IIIA: The Affordable Care Act. eligible beneficiaries. To be eligible, the Medicare ben- A First Step in Improving Transitions eficiary must have two or more chronic illnesses, such and Integrated Services as congestive heart failure, diabetes, other dementias (designated by the Secretary), chronic obstructive The Patient Protection and Affordable Care Act was signed pulmonary disease, ischemic heart disease, stroke, into law on March 23, 2010, and the supplemental bill, the Alzheimer’s disease and neurodegenerative diseases, Healthcare and Education Reconciliation Act in the Senate and other diseases and conditions designated by the was signed into law on March 25, 2010. There are five Secretary which result in high costs under this title. pilot projects and 30 demonstrations in the bill, and many Eligible participants must have had this medical of them could become a permanent part of the system that problem within the past 12 months, and have had a improves the transition and integration of care for older non-elective hospital admissions; or, within the past individuals and persons with disabilities. The healthcare 12 months, have received acute or sub-acute reha- reform bill includes the following opportunities: bilitation services, and have two or more functional 1. Healthy Aging, Living Well Evaluation of dependencies requiring the assistance of another per- Community-Based Prevention and Wellness pro- son (such as bathing, dressing, toileting, walking, or grams (SEC.4202) for Medicare beneficiaries focuses feeding). This demonstration would begin on Jan. 1, on nutrition, physical activity, tobacco use, substance 2012. abuse, screenings, and referrals for treatment of chron- The goal of the demonstration is to: ic diseases. This five-year pilot provides grants to state health departments for screening and education for • Reduce preventable hospitalizations. 55 to 64 year-olds. There are also funds for evaluat- • Prevent hospital re-admissions. ing evidence-based prevention programs for Medicare • Reduce emergency room visits. beneficiaries from the Administration on Aging (AoA) • Improve health outcomes commensurate with the and Chronic Disease management programs. The total beneficiaries’ stage of chronic illness. amount of funding for this program is $50 million, 3. Community-Based Transitions Demonstration and it will operate from 2010 to 2014. There is also a (SEC.3026) focuses on improving outcomes during Community Transformation Grant (SEC.4202) that transition periods for high risk Medicare beneficiaries allows national community-based organizations and with cognitive impairment, depression, a history of state and local governments to receive grant funding multiple re-admissions, or any other chronic disease to implement and evaluate comprehensive programs or risk factors as determined by the Secretary. Also, that will reduce the incidence of chronic diseases. The the older adult, or person with a disability, must have grant appears to focus on nutritional programs. a minimum Hierarchical Conditions Category (HCC) 2. Independence at Home Demonstration (SEC.3024) score that will be determined by the Secretary. This establishes an incentive-based system using a spending demonstration will begin Jan. 1, 2011. One service target, and a risk corridor for primary care physicians that is mentioned in the demonstration is medication or nurse practitioners to be paid for care coordination, review and medication management. Priority will be and must provide home-based primary care. A home given to grant applicants that are Area or State Units health agency could apply to be an “Independence on Aging, or to providers that operate in medically at Home” provider as long as it uses physicians and underserved and/or rural areas. nurse practitioners. It must also serve at least 200

An AAHSA White Paper 5 4. Hospital Re-Admission Reduction Demonstration will still receive its FFS payment, but there would be (SEC.3025) reduces the payments (base Diagnosis- an additional payment that is based on expenditure Related Group (DRG) plus the adjustment factor) benchmarks to be determined by the Secretary. ACOs to hospitals with poor re-admission rates. There is will be sanctioned if they avoid caring for high risk an exemption for small, rural hospitals and for sole patients. This program will be implemented by Jan. community provider hospitals. The Secretary will 1, 2012, and represents an excellent opportunity for determine which hospitals have high rates of re- home health agencies. admission. This demonstration will be a catalyst for 7. Patient Navigator (SEC.3510) Demonstration is a hospitals to partner with home health providers, other four-year demonstration grant that involves a pro- sub-acute and home and community-based service vider who is paid to coordinate care for Medicare providers to reduce re-admissions. This program will beneficiaries with chronic diseases. Funding for this begin Oct. 1, 2012. program is $3.5 million. Home health nurses and 5. The Bundled Payment Pilot (SEC.3023) is a five-year social workers would be eligible to become Patient demonstration that provides a bulk payment shared by Navigators. This demonstration will be in place from a hospital, a physician group, a skilled nursing facility, 2011 to 2015. This concept relates to a 2005 bill that and a home health agency. Payment during the pilot was signed by Pres. Bush that never received appro- includes bundled payments and bids by providers for priations. an episode of care. The demonstration will work on 8. Hospice Concurrent Care Demonstration developing a “Patient Assessment Instrument” and (SEC.3140) is a three-year demonstration that will quality measures for post-acute care. The Agency for involve 15 hospice providers who will combine home Healthcare Research and Quality (AHRQ) will work health and hospice provider services. This demonstra- with the Secretary to determine quality measures tion is an opportunity for hospice providers who also for this pilot. The quality measures must assess the operate home health agencies. patient’s functional status improvement, rates of discharge to the community, re-admission rates to the 9. Health Homes Demonstration (SEC.2703) establishes hospital and to the emergency room, incidence of “Health Homes” to coordinate care for individuals health-acquired diseases, patient perception of care, with chronic diseases through an optional Medicaid efficiencies in care, and person-centered care. state plan amendment, beginning on Jan. 1, 2011. Health Homes represent a team of health profes- 6. Medicare Shared Services Program (SEC.3022) is a sionals that may include a physician’s group, a home three-year program that will enable providers of ser- health agency, and other providers. The patient must vices and supplies for Medicare beneficiaries to work have at least two chronic diseases or a persistent men- together in Accountable Care Organizations (ACOs) tal health condition to be enrolled in a Health Home. that cover a minimum of 5,000 Medicare beneficia- The program will focus on mental health, substance ries. The ACO is responsible for the cost and quality abuse, asthma, diabetes, heart disease, and obesity. of the overall care. A hospital and physician practices Health Homes will be required to provide comprehen- are two organizations within the ACO; however, home sive case management, care coordination, patient and health and other providers are an important part of family support, and information and referral services. the process. The program encourages the use of tele- States can receive planning grants to initiate this pro- health and remote monitoring. The Medicare provider

An AAHSA White Paper 6 gram, and interested providers should discuss this messaging and nomenclature. In order to fund the program with their state Medicaid Directors. EHR grants and two other long-term care grant programs (that provide incentives for staff training and 10. Medication Management in the Treatment of development and improving management practices), Chronic Disease Grants program will begin on May $67.5 million has been made available. 1, 2010. A licensed pharmacist, working with the rest of the interdisciplinary team, will work with targeted 13. Use of Culture Change and Health Information individuals who are taking four or more prescription Technology (HIT) in Nursing Homes Demonstration medications for the treatment of chronic diseases. This requires the Secretary to conduct a demonstration program involves an assessment, an initial medication project to develop best practices in skilled nursing review, formulation of a medication treatment plan, facilities and nursing facilities on the use of infor- initiation of a medication administration therapy, mation technology to improve resident care. One monitoring for safety and effectiveness, and the provi- or more competitive grants will be implemented by sion of education and training on the appropriate use March 2011, and will not last longer than three years. of medication by the patient. Currently, there is not a specified amount of funding for this demonstration. 11. Evaluation of Integrating Care around Hospitalization Demonstration (SEC.2704) requires 14. There are two new agencies that will foster health- an application from a state, although the state will care reform within the system. An AAHSA member need providers to implement the program. The dem- could work with these agencies to promote innovative onstration will operate from Jan. 1, 2012 to Dec. models of care. The first, the Center for Medicare 31, 2016, and up to eight states will be chosen to and Medicaid Innovation, will develop a home health participate. States will work with providers to target chronic care management demonstration, and new Medicaid populations based on diagnosis and/or loca- funding mechanisms that will result in costs savings tion to improve their care and reduce hospitalizations. through the better coordination and management of Partnering with a local hospital on this demonstra- care by the newly established ACOs. ACOs will have tion is recommended; interested organizations should the opportunity to use telehealth, remote patient encourage their state’s Medicaid Director to apply. monitoring, and other enabling technologies. This new agency will be launched on Jan. 1, 2011. The sec- 12. Certified Electronic Health Record (EHR) Grant ond new agency, the Federal Coordinated Healthcare Program for Long-Term Care Facilities will begin in Office, will seek to improve the integration of services fiscal year 2011. These grants are to be used to offset between Medicare and Medicaid and will work to pro- costs related to purchasing, leasing, development, and mote the PACE model. implementing certified EHR technology and may be used for any computer infrastructure, including hard- Section IIIB: Accountable ware and software, upgrading current systems, and Care Organizations (ACOs) staff training. Long-term care facilities that receive grants are required to participate in state-level health In 2007, Dartmouth’s Institute for Health Policy and information exchange activities, where available. The Clinical Practice, headed by Dr. Elliot Fisher and Secretary is required to adopt electronic standards Dr. James Weinstein, teamed up with the Brookings for the exchange of clinical data by long-term care Institution’s Mark McClellan to create The Brookings- facilities, including, where available, standards for Dartmouth ACO Learning Network. The ACO Learning

An AAHSA White Paper 7 Network will serve as a support tool for providers in Although the full results are not yet available, the expe- transition to the ACO framework. An ACO is a group of rience of the first three years was mixed. Some groups providers that are held responsible for the quality and cost qualified for bonuses, but other groups discovered that of healthcare for a population of Medicare beneficiaries. costs for patient care grew faster than the comparable An ACO is a combination of one or more hospitals, pri- Medicare beneficiaries in the same area. Some possible mary care physicians, and possibly specialists that would reasons why there were mixed results are that some groups be accountable for total spending and quality of care had limited ability to manage the care of non-enrolled for the Medicare patients served. Bonuses and penalties patients and that participating providers were still paid would be tied to overall Medicare spending and quality on a fee-for-service basis, with continued incentives to measures3. The ACO has been highlighted in healthcare increase service volume. reform, but, its current success has been limited to a hand- Although much of the discussion of ACOs so far has been ful of healthcare systems across the country. in the context of Medicare, there is growing interest in There are three tiers of operations of an ACO. Tier 3 has extending the concept to patients covered by Medicaid a high financial risk and has full or partial capitation and and private insurance. Cooperation among multiple extensive bundled payments. There are also additional payers in promoting ACOs could have several possible incentives, including that the highest level of shared sav- advantages. Providers may be more likely to modify their ings and bonuses are given if the per beneficiary spending practices if most of their patients, not just those with one is below agreed-upon target, but the greatest amount of type of coverage, are included in the ACO population. risk of spending is above the agreed-upon target. Efforts to improve care may be more effective if several payers are using uniform performance measures and qual- The Tier 2 has a moderate financial risk, and the mode ity standards. Also, a multi-payer ACO may have enough of payment is either fee-for-service, partial capitation, or patients to allow a meaningful focus on populations with some bundled payments. There are also additional incen- special needs. tives, including more shared savings and bonuses if per beneficiary spending is below agreed-upon target, but also ACOs have the potential to provide, and manage with some risk if spending is above agreed-upon target. patients, the continuum of care across different institutional settings, including ambulatory and inpatient The Tier 1 model has a low financial risk with a fee-for- hospital care and post-acute care. The ACO will have the service payment. Additional incentives include some capability of efficiently planning budgets and resource shared savings and bonuses if the beneficiary’s spending is needs. The large number of individuals served by the ACO below the agreed-upon target. will help the Medicare Payment Advisory Commission Some of the components of an ACO, such as invisible (MedPAC) and the Dept. of Health and Human Services enrollment and shared savings, have been tested in a five- use a comprehensive, valid, and reliable performance year Medicare physician group practice demonstration measurement that will help evaluate and replicate the project that began in 2005. Ten group practices, most program. ACOs will need to prove that they can succeed of them hospital-affiliated, were given bonus payments in more states, and show whether or not they are a viable if they achieved quality standards and reduced costs. model in rural areas.

Examples of ACOs based on integrated delivery systems 3 Fischer, Elliott S., Staiger, Douglas O.; Bynum, Julie P.W.; Gottlieb, Daniel J. Creating Accountable include the Geisinger Health System, Group Health Care Organizations: The Extended Hospital Medical Staff, Health Affairs, 26, no. 1 Online at: http:// content.healthaffairs.org/cgi/content/abstract/26/1/w44 Cooperative of Puget Sound, and Kaiser Permanente.

An AAHSA White Paper 8 Multi-specialty group practices that many times own, or 2. Care Transitions ProgramSM partner with, a hospital to coordinate care could form Dr. Eric Coleman, of the University of Colorado, devel- an ACO. Good examples of this delivery system are: oped the Care Transitions ProgramSM. The model has the Atrius Health (eastern Massachusetts), Cleveland Clinic, following components6: Marshfield Clinic, Mayo Clinic, (Physician-Hospital • A patient-centered record that consists of the essential Organizations) Advocate Health (Chicago), Middlesex care elements for facilitating productive interdisciplin- Hospital (Connecticut), and Tri-State Child Health ary communication during the care transition. Services. Good examples also include virtual physician organizations led by individual physicians and local • A structured list of critical activities designed to medical foundations, such as Community Care of North empower patients before discharge from the hospital Carolina and the North Dakota Cooperative Network. or nursing facility.

There is a concern by many providers that federal ACO • A patient self-activation and management session with policies will conflict with existing antitrust regulations. a Transition Coach™ in the hospital, designed to help The federal government will have to assure that ACOs patients and their caregivers understand and apply the incorporate integration and improve care without infring- first two elements and assert their role in managing ing on consumer choice. transitions.

Section IIIC: Existing Transitions • A Transition Coach™ who will make follow-up visits and Integrated Services Programs in the Skilled Nursing Facility (SNF) and/or in the home and make accompanying phone calls designed to sustain the first three components. 1. The CARE Tool “Care Transitions in Communities,” a new program from Dr. Coleman focuses the intervention with the patient on the Centers for Medicare & Medicaid Services (CMS), what he calls The Four Pillars™: uses a standardized “Continuity Assessment Record and Evaluation” (CARE) tool to help Quality Improvement 1. Medication self-management: A patient is knowl- Organizations (QIOs) better serve seriously ill Medicare edgeable about medications and has a medication beneficiaries. The CARE tool uniformly measures and management system. A “Medication Discrepancy compares Medicare beneficiaries’ health and functional Tool” helps remedy transition-related medication status across provider settings at critical times, including problems. transfers4. The online instrument, which will provide qual- 2. Use of a dynamic patient-centered record: A patient ity and payment information to Medicare, is being tested understands and utilizes the Personal Health Record in 10 locations5. (PHR) to facilitate communication and ensure the continuity of the care plan across providers and settings. The patient or informal caregiver manages the PHR.

3. Primary care and specialist follow-up: A patient 4 Tobin, J. “Continuity Assessment Record & Evaluation.” PowerPoint presentation for the Centers for Medicare and Medicaid Services. Online at: http://www.cfmc.org/value/files/TransitionalCareLearning- schedules and completes follow-up visits with the Sess-05-15-08jt.pdf. 5 Demonstration sites include: Boston, Mass.; Chicago, Ill.; Rochester, N.Y.; Rapid City, S.D.; San 6 Coleman, E. et al. University of Colorado Health Services Center Division of Healthcare Policy and Francisco, Calif.; Tampa, Fla.; Seattle, Wash.; Dallas, Texas; Louisville, Ky.; and Lincoln, Neb. Research. Online at http://www.caretransitions.org/

An AAHSA White Paper 9 primary care physician, or specialist physician, and is 4. Project BOOST empowered to be an active participant in these inter- Another promising model is the “Better Outcomes for actions. Older Adults through Safe Transitions” (BOOST) program. Project BOOST helps hospitals reduce re-admission 4. Knowledge of red flags: A patient is knowledgeable rates by providing them with proven resources and expert about indications that their condition is worsening mentoring to optimize the discharge transition process, and knows how to respond. enhance patient and family education practices, and On April 13, 2009, CMS announced the selection of improve the flow of information between inpatient and 14 communities to participate in its Care Transitions outpatient providers. BOOST has four key components8: Program, a post-acute program aimed at reducing the 1. A comprehensive intervention based on the best avail- number of re-hospitalizations for older adults when they able evidence. are transitioning from the hospital to a skilled nursing facility or to home. Each program is implemented by a 2. A comprehensive BOOST “Implementation Guide” state QIO and monitored until 2011. that provides instructions and project management tools to help multi-disciplinary teams to plan, imple- 3. Transitional Care Nurse Model ment and evaluate the intervention. Mary D. Naylor, Ph.D., R.N., Director of the New 3. The BOOST “Mentoring Program” is provided cour- Courtland Center for Transitions and Health at the tesy of a grant from the John A. Hartford Foundation, University of Pennsylvania, School of Nursing, developed and includes face-to-face training for hospital staff the “Transitional Care Nurse” model7. This model desig- and a year of expert mentoring and coaching to revise nates staff to follow enrolled patients from hospitals into the discharge process and implement BOOST. their homes, and using an evidence-based care coordination approach, provides services designed to streamline 4. The BOOST “Collaborative” has been established so plans of care and interrupt patterns of frequent acute staff at BOOST sites are able to communicate with hospital or emergency department use and health status and learn from each other via the BOOST Listserv, decline. The Transitional Care Nurse collaborates with online community site, and quarterly all-site telecon- patients’ physicians in the implementation of tested pro- ferences. tocols with a unique focus on increasing patients’ and This program was initiated in Sept. 2008. Already there caregivers’ ability to manage their care. The Transitional are 65 BOOST sites across 24 states nationwide. There is Care Nurse is an expert in providing comprehensive care no comprehensive data on BOOST at this time; however, to the chronically ill, versed in national standards of care the early reports from Project BOOST sites are promis- delivery, and experienced in providing both acute and ing. At Piedmont Hospital in the Atlanta area, the rate community-based services. Transitions from acute to of re-admission among patients under the age of 70 par- community and transitions in health status are monitored ticipating in BOOST is 8.5 percent, compared with 25.5 and managed to improve patient care and outcomes. percent among non-participants. The re-admission rate Each nurse is in charge of a caseload of 15 to 20 patients, among BOOST participants at Piedmont over the age with an average of 18 patients. The nurse also helps the of 70 was 22 percent, compared with 26 percent of non- patient’s family/caregivers to achieve their goals as a care- participants. When St. Mary’s Medical Center in St. Louis giver. 8 Project BOOST. Online at http://www.hospitalmedicine.org/ResourceRoomRedesign/RR_CareTransi- 7 Transitional Care Model. Online at http://www.transitionalcare.info/index.html tions/html_CC/project_boost_background.cfm

An AAHSA White Paper 10 implemented BOOST at its 33-bed hospitalist unit, 30-day of a Medical Home. As of May 4, 2010, CMS has three re-admissions dropped to 7 percent from 12 percent with- medical home demonstrations currently in development. in three months. Patient satisfaction rates also increased The Medical Home is another example of collaborative markedly, to 68 percent from 52 percent9. efforts on the provider level that help older people manage their chronic conditions and avoid hospitalizations. 5. Guided Care A consumer’s Medical Home is centered in a primary The Guided Care™ program, developed at Johns Hopkins healthcare setting, where a partnership develops between University in Baltimore, Maryland, strives to meet the the patient, his or her family, and the primary healthcare growing challenge of caring for older adults with chronic practitioner. These partners work together to access all conditions and complex health needs. At the center of medical and non-medical services the consumer needs. To the model is a “Guided Care Nurse,” who works with the promote coordination and continuity of care, the Medical older consumer’s primary care physician to assess the con- Home maintains a centralized, comprehensive record of sumer and caregiver at home, create an evidence-based all health-related services. CMS has shown interest in the care plan, monitor the consumer’s condition, coordinate Medical Home concept as a way to coordinate care for care transitions and promote patient self-management older people with multiple illnesses that require regular through coaching, education and access to community medical monitoring, advising, or treatment. It is conceiv- resources. A pilot study found that Guided Care™ resulted able that an ACO could consist of a group of medical in greater consumer satisfaction and lower insurance costs. homes partnering with a hospital. In a pilot study, patients who received Guided Care rated their quality of care significantly higher than usual care 7. Stanford Self-Management Program patients. The average insurance costs for Guided Care for People with Chronic Health Problems patients were 25 percent lower over a six month period10. The Stanford Patient Education Research Center has The program is currently being tested at eight primary developed, tested, and evaluated self-management pro- care sites in the Baltimore-Washington, D.C. area in a ran- grams for people with chronic health problems. All of domized trial involving over 900 patients, 300 caregivers, these programs are designed to help people gain self-con- and 48 primary care physicians. fidence in their ability to control their symptoms and how their health problems affect their lives. This model uses 6. Medicare Medical Home small-group workshops that generally meet for six weeks, The Medicare Medical Home Demonstration (MMHD) meeting once a week for about two hours, which are led will test a re-design of the primary healthcare delivery by a pair of lay leaders with health problems of their own11. system to provide targeted, accessible, continuous and The meetings are highly interactive, focusing on building coordinated, patient-centered care to high-need popula- skills, sharing experiences and support. Kaiser Permanente tions. Section 204 of the Tax Relief & Healthcare Act of and Group Health Cooperative of Puget Sound have 2006 mandated a demonstration in up to eight states to adopted the Stanford Chronic Disease Self-Management care for high-need Medicare beneficiaries. The three-year Program. demonstration provided reimbursement via a care man- CMS awarded $27 million in grants on March 30, 2010, agement fee to physician practices for the unique services for the “Communities Putting Prevention to Work 9 Project BOOST. Online at http://www.hospitalmedicine.org/ResourceRoomRedesign/RR_CareTransi- Chronic Disease Self-Management Program,” funded by tions/html_CC/project_boost_background.cfm 10 Boult, C. et al. “Early Effects of ‘Guided Care’ on the Quality of Health for Multimorbid Older Persons: A Cluster-Randomized Controlled Study.” Journal of Gerontology: Med. Sci., 63A(3)321-327. 11 Stanford Self-Management Programs. Online at: http://patienteducation.stanford.edu/programs/

An AAHSA White Paper 11 the American Recovery and Reinvestment Act of 2009. models uses different methods to achieve positive care It will allow 45 states, Puerto Rico, and the District of outcomes. The diversity of communities requires the use Columbia to provide self-management programs to older of multiple approaches to improve transitions and inte- adults with chronic diseases build statewide delivery grate the services for older individuals and all persons with systems and develop the workforce that delivers these pro- chronic diseases. grams. Section IIID: Housing with Services Bundling It is difficult to address the need for more care coordina- Bundling services for reimbursement is included in the tion and HCBS without addressing the parallel need for Affordable Care Act, but is not a new concept. From more affordable housing for older adults. Together, hous- 1992 to 1996, Medicare conducted a demonstration ing and services play a major role in helping older people project at seven hospitals for patients undergoing heart remain independent. bypass surgery. The hospital and physicians received a bundled payment. For the most part the demonstration showed that bundling could reduce costs without hav- Why Housing with Services? ing a negative impact on quality of care. Some experts • Economy of scale: a concentration of clients in one believe that the best way to have doctors and hospitals location potentially lowers cost for service providers. work efficiently together is to pay them together. The • Increased access: services available onsite allows for Mayo Clinic, Geisinger Health System, Kaiser Permanente, easy access, particularly for frailer residents and those and Intermountain Health have hospitals with salaried with limited transportation options. physicians, unlike most hospitals in America, and they are all known for their low-cost and high-quality care. • Increased participation: easier access may increase Some experts say that bundled payments are reminiscent participation in programming, enhancing continuity of the capitation fees that many Health Maintenance of care and follow-up services. Organizations (HMOs) implemented in the 1970s. Unlike • Care coordination: on-site service coordinators help these HMOs; however, bundling pays doctors and hos- residents identify and access needed services. pitals after treatment has been completed and includes pre-determined quality controls such as monitoring rates • Consumer preference: supports residents to remain in of in-hospital infections and re-admissions12. It is impor- their own homes and communities. tant that the bundling model includes long-term services • Savings- to Medicare and Medicaid through reduced and support providers in order to assure continuity of care emergency room and hospital visits and preventing when the person is discharged back into the community. premature transfers to nursing homes. Long-term services and support providers have a long history of providing comprehensive case management and • Savings: to local communities for reduced 911 calls. care coordination. • Savings: to community service providers through With all of the various models available, it is important economies of scale due to congregate settings. to not focus on one model. It is evident that each of these • Savings: to housing properties through decreased damages to units and resident turnover. 12 Shih, Anthony; Davis, Karen; Schoenbaum, Stephen C.; Gauthier, Anne; Nuzum, Rachelle; McCarthy, Douglas. Organizing the U.S. Health Care Delivery System For High Performance. August 2008. Online at http://www.commonwealthfund.org/usr_doc/Shih_organizingushltcaredeliverysys_1155.pdf

An AAHSA White Paper 12 Why the Need for Care technology that promotes safety and health, service coor- Coordination in Senior Housing? dinator training, assistance with case management, adult • By 2030, the senior population will double and seniors day services, and the implementation of meal programs in will represent 20 percent of the population. subsidized housing. It would also require the State Units on Aging to include housing with services as a part of their • By 2050, one in four seniors will be 85 or older. state plan on aging services. This addition to Title III has • Low-income seniors disproportionately live in apart- the potential to improve the collaboration between Area ments and have less family support. Agencies on Aging (AAAs) and local subsidized housing providers. The goal is to eliminate some of the barriers • Median age of residents in the Dept. of Housing and that currently exist with housing with services. Urban Development (HUD) senior housing is 74 years-old (30 percent are age 80 and older) and their State-Supported Housing with Services Programs median annual income is $10,200. Vermont’s Seniors Aging Safely • Studies show subsidized senior renters experience at Home (SASH) Program more chronic health conditions and are frailer than The Seniors Aging Safely at Home (SASH) demonstra- non-subsidized renters and homeowners. tion, currently in the planning stages in Vermont, creates The taskforce noted that state regulations concerning the an integrated system of partnering by a hospital, PACE frailty of clients in senior housing is one of the main bar- program, home health agency, and senior housing facility. riers. Innovations, including allowing PACE, adult day It uses a “medical home” concept to connect outcomes services, and homecare services co-located in senior hous- and reimbursement. It also establishes an assessment ing, are discouraged by many states. Many states believe process that assures that housing residents have access that the housing facility then becomes an unlicensed to services when needed. In the Vermont 2008 legislative nursing care facility. An “Advance Notice of the Proposed session, AAHSA member Cathedral Square Corporation Rulemaking,” that was released in 2009 questions if a requested funding to develop SASH to better meet the provider of housing should be the same as the provider needs of seniors aging in place in senior housing facilities. of services. Also asked was, “What are the ‘characteris- The Vermont General Assembly appropriated $100,000 in tics of a home’ that makes it a person’s home and not fiscal year 2009 funds. The Vermont Health Foundation an unlicensed assisted living?” There needs to be further matched the state appropriation with a commitment of discussion on this issue in order to develop solutions that $100,000. The model’s goal is to achieve better health out- maintain quality in care coordination without hindering comes and more efficient use of Medicaid and Medicare the older individual’s choice to age in place. dollars.

To ensure a major focus on outcomes and cost savings Housing with Services Program Cathedral Square partnered with AAHSA. AAHSA is in the Older Americans Act (OAA) conducting a national demonstration of housing-based AAHSA gave testimony at the OAA Re-authorization models, and its applied research arm, the Institute for the Listening Forum on February 5, 2010 that was sponsored Future of Aging Services (IFAS), has teamed up with the by the Administration on Aging asking for the inclusion of new University of Vermont Center on Aging and Harvard a “Housing with Services” program under Title III of the Medical School to measure the health and financial out- OAA. This proposed program would cover chore services, comes of the SASH model. personal care, non-emergency medical transportation,

An AAHSA White Paper 13 Over the past year, 20 organizations have lent their sup- state subsidized elderly housing units in nearly 700 devel- port to the SASH initiative. The model is being designed opments are operated by local housing authorities (LHA). at Heineberg Senior Housing where 59 seniors have vol- Housing managers and LHA directors report that older unteered to help shape the design of this new model of buildings have higher vacancy rates, tenants have frequent care coordination at the local level. Case studies of existing medical emergencies, and housing staff lack knowledge residents at Heineberg Senior Housing have demonstrated about community services. Buildings often have multiple that the absence of basic supports for seniors at home can provider agency staff and case managers working in the result in extraordinary expenses for patients, hospitals, and buildings. The Executive Office of Elder Affairs (EOEA) nursing homes. reported that services were delivered inefficiently and the ability of the state’s homecare program to support aging in The SASH initiative focuses on five problem areas that place was limited by the absence of on-site staff and access were documented in the needs surveys conducted with to 24-hour assistance for emergencies and unscheduled residents at three Cathedral Square senior communities in needs. the fall of 2008: The homecare program serves an average of 40,000 older 1. Medication management adults each month, including 5,954 Medicaid HCBS 2. Falls waiver participants. About half of the 40,000 homec- 3. Chronic conditions are program clients live in subsidized housing. The 4. Lifestyle barriers to good physical and mental health Supportive Housing Program improves the efficiency of 5. Cognitive impairments and mental health problems in-home services and expands the range of services avail- The model is well under development, built around the able. Prior to the program, case managers were assigned existing provider community and utilizing evidence to individual clients or tenants, individual service plans based practices. The effectiveness of the model, and its were developed by case managers, and providers assigned sustainability, will depend upon healthcare reimburse- workers to serve specific individual clients. Large subsi- ment reforms and the degree to which the SASH team is dized housing buildings often had multiple workers from integrated into overall system reforms. After the model is as many as nine provider agencies entering and leaving a finalized in 2011, it will be demonstrated and rigorously building. Similarly, multiple case managers, assigned to evaluated at up to five locations in Vermont in public individual clients, added to the number of people serv- housing and publicly subsidized housing. The goal is to ing a building. To reduce travel time and increase service design a model that is replicable in any residential setting hours, providers were encouraged to cluster services in and is scalable within the framework of a national net- elderly housing buildings with significant numbers of ten- work. ants who received homecare services. This precursor to the Supportive Housing Program assigned one or more Massachusetts Supportive Housing Program case managers to a building, depending on the number of The Massachusetts Supportive Housing Program includes homecare consumers, and limited the number of service a state-funded homecare program for older adults, a providers serving tenants. To improve efficiency, work- Medicaid elder HCBS waiver program, a group adult fos- ers were assigned to tasks rather than to individuals13. For ter care program (that serves Medicaid beneficiaries in example, one worker would shop for groceries for several subsidized housing and assisted living settings), and OAA tenants. The program also serves private pay residents programs. Massachusetts has an extensive supply of state 13 Mollica, Robert; Morris, Michael. Massachusetts Supportive Housing Program. Rutgers Center for and federally subsidized elderly housing. About 32,400 State Health Policy. National Academy for State Health policy. January 2005

An AAHSA White Paper 14 who may not be eligible for the above programs. Sites are room, 24 hour security, community meals, and social and required to have the capacity to serve meals or be a Title recreational activities. III-C congregate meal site. In 1998, Connecticut initiated the Assisted Living The Supportive Housing Program added key dimensions Demonstration Project. The project required the state to to the homecare program, including: apply for a Medicaid waiver to fund assisted living services and to provide funding for the creation and on-going • A service coordinator is assigned to each building. The subsidy of new affordable assisted living units. In 2000, service coordinator’s role is broader than the tradi- additional legislation expanded the assisted living services tional case management role. The Supportive Housing into both existing state-funded congregate housing for the Program service coordinator is available to all resi- elderly properties and federally-subsidized elderly hous- dents in the building, including residents who are not ing developments. Specifics on the three different settings eligible for subsidized services and who are willing to where assisted living services are provided include14: pay privately. 1. New assisted living communities: State funds were • Case managers serve older adults who are eligible for allocated for the development costs and rent subsidies the HCBS waiver or the state-funded homecare pro- of up to 300 new units in five affordable assisted living gram. Case managers complete functional assessments, communities throughout the state. The facilities could determine functional eligibility, develop a care plan, be newly constructed, rehabilitated, or adapted for use authorize services, monitor service delivery, and peri- as assisted living units. At least 40 percent of the units odically reassess consumer functional needs. in the assisted living developments were required to A formal evaluation of the program has not yet been serve households making less than 50 percent of the conducted, but preliminary reports have found that the area median income. Supportive Housing Program saves $3,205 in federal 2. State-funded congregate housing for the elderly: All and state spending ($1,287 in net state savings) for every state-subsidized congregate housing communities are month that a nursing home placement is avoided. eligible to participate in the assisted living services program. Currently, 16 of the 24 sites are participat- Connecticut’s Congregate ing. In addition to receiving the package of congregate Housing for the Elderly Program housing services (see details below), residents who Connecticut’s Congregate Housing for the Elderly meet the functional eligibility requirements may also Program is a publicly subsidized congregate housing pro- receive assisted living services. gram for low-income older adults who have temporary or periodic difficulties with one or more essential activities 3. Federally-subsidized senior housing: Assisted living of daily living. Funded by the Department of Economic services may be provided in up to four HUD-funded and Community Development (DECD), the program senior housing properties (either Section 202 or provides grants or loans to construct or rehab congregate Section 236 sites). Currently, four properties are par- rental housing units. The program also subsidizes those ticipating. residents who cannot afford to pay the full cost of services. Assisted living services in all three settings are provided Residents pay a minimum rent and a congregate service through the Connecticut Homecare Program for Older charge, which is based on their adjusted income. Services include housekeeping, emergency call systems in each 14 Inventory of Affordable Housing Plus Services. Institute for the Future of Aging Services. June 2006.

An AAHSA White Paper 15 Adults program and paid for through either a Medicaid demonstration project to determine if the Medicare/ waiver component or a state-funded component (for per- Medicaid integration model used by On Lok could be sons whose income exceeds the Medicaid waiver limits). replicated. PACE was not authorized as a permanent Medicare/Medicaid benefit until 1997. In order to be eligible for the CHPCE, participants must meet the program’s functional and disability criteria. The all-inclusive component of PACE means that clients CHPCE pays for medical and non-medical support servic- receive a coordinated package of care and services that es, including assessment, care management, adult day care, combines primary and acute medical services with institu- home-delivered meals, homemakers, home health aides, tional and community-based long-term services like adult skilled nursing visits, physical, occupational and speech day care, in-home services, meals, and transportation. therapy, mental health counseling, companion services, While housing is not part of the PACE benefit package, chore services, and emergency response systems. many PACE organizations have developed partnerships with housing providers in order to maintain frail seniors Section IIIE: Program of All-Inclusive in the community. Care for the Elderly (PACE) A large initial investment of $2 million to $4 million and The Program of All-Inclusive Care for the Elderly (PACE) the financial risk of starting a PACE has been a challenge was developed to help frail older adults and older people for providers and a major barrier to the development of with disabilities remain in the community. PACE organi- the program. The Deficit Reduction Act of 2005 helped zations use capitated payments from Medicare, Medicaid reduce some of this burden by providing stop-loss funding and, to a limited extent private payers, to create a pool that reduced the initial start-up costs for 15 rural PACE of funds that meet the needs of their participants. These programs. Similar federal and state assistance would go a funds allow PACE to provide all the care and services long way toward making PACE available in more states. covered by Medicare and Medicaid, as approved and coor- The lack of consistency in state laws and long-term ser- dinated by a PACE interdisciplinary team. As a flexible vices and supports policy is one factor that slows the model of care, PACE can also provide medically-necessary overall growth of PACE. The lack of recent evidence-based care and services that are not covered by Medicare and studies to support PACE also hinders the state advocacy Medicaid. There are currently 70 operating PACE pro- efforts to promote the program. Better longitudinal stud- grams in 30 states, serving about 18,000 individuals. Since ies on PACE and thinking about all populations, not just PACE organizations assume the full financial risk for care, the very frail, are necessary. PACE would also be effective the program has built-in financial, quality, and consumer as a model to improve outcomes, especially re-admissions choice incentives. For example, PACE provides preventive to the hospital for individuals with chronic diseases, even care as a way to avoid a more expensive level of care, such though they may not fit the criteria of having a skilled as a nursing home placement, down the road. need. In 1985 and 1986, Congress authorized two separate bud- Despite their great potential to serve older people living in get acts that laid the groundwork for the PACE program. the community, PACE providers face several serious chal- The Consolidated Omnibus Budget Act of 1985 authorized lenges, which require further research to identify workable the original demonstration project for On Lok, a PACE solutions. These include: precursor that delivered long-term services and supports to people living in San Francisco’s Chinatown. The • Frailty factor phase out: In the past, PACE providers Omnibus Reconciliation Act of 1986 authorized the PACE received the same payment for every Medicare-eligible

An AAHSA White Paper 16 PACE participant. In 2004, however, CMS began vider applications directly to only CMS for approval, thus phasing in a new risk-adjusted methodology, called reducing a state’s involvement. This arrangement would the Hierarchical Condition Categories (CMS-HCC), be similar to Medicare coverage for hospice and home which pays PACE and other Medicare capitated pro- health. The concern with this approach is that the states grams a higher rate for enrollees whose care is likely to would feel compromised regulating a program without cost more. Until recently, a “frailty adjuster” allowed the provider application going through it first. CMS relies reimbursement rate-setters to include additional heavily on the states doing the reviews of PACE applica- Medicare expenditures that might be necessary to tions and rarely has staff on the local level to assist with care for a community-based, functionally-impaired the reviews. population. The current frailty adjuster calculation The Independence at Home (IAH) program demonstra- methodology is based on a self reported survey that tion in healthcare reform provides a positive incentive relies heavily on the opinion of the participants being process where a program would receive a percentage surveyed. This opinion-based survey causes a bias in of savings after a certain amount of initial savings is reporting and the subsequent calculation of the frailty achieved. A PACE program could possibly model itself factor. In 2008, CMS began implementing a new after this program. One problem with convincing states to methodology for calculating the frailty factor com- expand or implement a PACE is that the states do not see ponent of PACE payments. This new methodology, the savings produced by PACE (only the Federal govern- which will be phased in over the next five years, will ment sees the savings to Medicare). One possibility is to result in reduced Medicare payments for PACE. add an additional incentive payment that would be shared • Reimbursement connected to Medicare Advantage: by the PACE provider and the states when the PACE The healthcare reform bill exempts PACE from reduc- would show a savings to Medicare. This payment incen- tions in Medicare Advantage payments. tive would help cover the additional costs that a state may incur during the PACE application process and imple- • State reimbursement rates: No single methodology mentation, and thus could help fund PACE expansion exists for the development of a Medicaid capitation within the state. rate for PACE, so each PACE provider must negoti- ate rates with its respective state. States differ in their The Community Living Assistance Services and Supports approaches to rate setting, which adds to a lack of (CLASS) plan will assist people with paying the private standardization in reimbursement rates from state to pay portion of PACE. Also, the closing of the Part D state. doughnut hole, another component of healthcare reform, would help the PACE program lower premiums in the • No Medicaid mandates: Since PACE is not a federally future. mandated Medicaid program, states can decide not to offer PACE or to limit its expansion. A large PACE that cares for 2,000-plus participants could be an integral part of an ACO, and could receive money There has been a long standing feeling that PACE growth from this bundled payment program where everyone has been constrained because it has to be done on a state- would benefit if positive outcomes were achieved. A PACE by-state basis. States often say that they do not have the organization could establish its own ACO via its contract staff or expertise to oversee a PACE program. with a local hospital. One barrier is that ACOs tend to One idea is to develop a “Medicare only PACE” that serve large number of patients (at least 5,000), and there would allow new PACE programs to submit their pro- must be a large physician group involved. The payments

An AAHSA White Paper 17 for ACOs are based on spending targets, quality targets in independent living. The entrance fee may or may plus a risk adjuster. Adjustments are also made based on not be partially refundable upon termination of the regional wage differences. contract.

Some members of this taskforce suggest that PACE devel- • Type B (Modified Contract): under a Type B, or op its own methodology and be included in the federal law modified contract, a resident will also pay an entrance separate from Medicare Advantage programs and rates. fee and an ongoing monthly fee for the right to live in In the long-run, Medicare Advantage programs increase an apartment. However, in a Type B contract, a CCRC PACE costs. is obligated to provide an appropriate level of assisted living or skilled nursing, as in a Type A contract, but Another suggestion is to use “age bucket systems” as the only for a specific period of time (e.g., 30-60 days), comparable group (currently used in North Dakota) in or at a discounted rate for a stated period of time, or order to determine PACE rates. indefinitely (after which the market rate is paid). The entrance fee may or may not be partially refundable. Veterans’ Services and PACE There are a growing number of opportunities avail- • Type C (Fee for Service): under a Type C contract, able for innovative collaborations between the Veteran’s a resident typically pays an entrance and a monthly Administration and community-based long-term care fee, but the fees do not include any free or discounted providers to maintain frail older adults in the community. healthcare or assisted living services. Under a Type C The VA plans to enter contracts with PACE providers contract, residents pay the standard per diem if they for a total of $3 million. VA funds can be used to pur- need assisted living or nursing services, however they chase PACE services even if the veteran is not eligible for may receive priority or guaranteed admission for Medicaid. those services.

• Rental CCRC: while generally not thought of as “true Section IIIF: CCRCs and CCRC” since there is no, or minimal, entrance fee, Transitional and Integrated Care some communities that have independent apartments Some Continuing Care Retirement Communities and offer some kinds of assisted living or nursing ser- (CCRCs) offer homecare, home health, and adult day services will use the title of a CCRC. In a Rental CCRC, vices to residents and non-residents. There are four types the resident pays the prevailing rate for all services of CCRCs each with different entrance fees requirements offered. and monthly fee amounts: Through the “CCRC without Walls” and “CCRC Live at • Type A (Extensive Contract): under a Type A, or Home” models, older people living in their own homes extensive contract, a resident typically pays an upfront pay a membership fee and receive a package of services. entrance fee and an ongoing monthly fee for the right Many CCRCs are certified to provide Medicare services so to live in an independent apartment and also receive certain skilled nursing and other specific services may be certain services and amenities. Residents who require paid for in part by Medicare. A few CCRCs are certified assistance or health care may receive some services in to provide Medicaid services, which will pay for primarily their apartment or they may move to an assisted living nursing care. Some CCRCs have long-term care insurance or skilled nursing portion of the community, but they available as part of their contract to pay for certain health pay essentially the same monthly fee they were paying care services. Independently purchased long-term care

An AAHSA White Paper 18 insurance may or may not pay for care in a CCRC, so it’s investment to begin. In 2008, the average membership important for prospective CCRC residents to check with was $20,000, with a monthly fee of $470. Services include the company providing the policy. care coordination, an annual physical, home inspec- tion, home health services, access to/use of an emergency Opportunities for CCRCs response system, a meals program, adult day services, lim- “Intentional communities” (also sometimes referred to as ited transportation, assisted living services, nursing home the “Beacon Hill” model) could also improve the viability services, and social and wellness programs. The average of CCRC without walls type models. Another recent devel- age of entry was 76 years-old, the median annual income opment that could help a CCRC is the healthcare reform was $45,000, and the median liquid asset was $400,000. bill. It has the potential to assist through the following Cadbury at Home’s net operating revenue in 2007 was demonstrations: $275,000. In addition to the membership and monthly fees, the CCRC benefited from an increase in the number • The transitional care demonstration. of skilled nursing facility Medicare days, as well as the use • The hospital re-admission reduction demonstration. of the assisted living facility. • The patient navigator demonstration (where providers are paid to become patient navigators). Senior Health and Housing Initiative CCRCs have been doing quality care coordination for For Transformation (SHIFT) years, and there is a window of opportunity given the The “Senior Health and Housing Initiative For current move towards improving outcomes through Transformation (SHIFT)” model was developed by enhanced care coordination. There are five pilots and 30 Wesley Enhanced Living, a multi-site CCRC in suburban demonstrations in the recently passed healthcare reform Philadelphia. This model uses incentives and places a bill. All of these demonstrations and pilots stress wellness person in the middle of the “process” in order to try to programs, prevention, and chronic disease management, help someone earlier in life (possibly before their health and CCRCs have always focused on these health programs. conditions worsen) as opposed to PACE (which requires Medical homes that were funded by both the Recovery that a person be nursing home eligible). The program Act and the Affordable Care Act, present possibilities for is designed to bring the Medicaid system into play if a CCRCs, especially if they are using a geriatric clinic as part CCRC client no longer has funds to pay for care. It’s a of their operation. The Independence at Home demon- campus-bound program and has an admissions process stration is also a good opportunity for CCRCs where the similar to a regular CCRC. The SHIFT monthly fee would CCRC physician group could implement a “house call” cover all services (as is the case with a Type A CCRC). program. SHIFT is a concept that combines two existing and successful models. It employs the coordinated, integrated, Innovative CCRC Examples at-risk approach inherent in the PACE model, which is Cadbury at Home a day-care based program for frail elderly, on a CCRC A best practice in providing the CCRC without walls platform that provides multiple levels of care and hous- model is at the “Cadbury at Home” program in New ing. The purpose of the SHIFT model is to integrate the Jersey. Cadbury at Home offers Type A, B, and C con- healthcare and housing needs of the elderly and provide a tracts, including a long-term care insurance option and lower cost, higher quality residential care option for peo- a 100 percent refundable fee for service agreements. The ple who would not otherwise be able to afford the lifestyle Cadbury at Home program needed a small initial capital provided through a CCRC. SHIFT aims to coordinate,

An AAHSA White Paper 19 and manage intensively, all acute, post-acute, and long- 2. SHIFT operates an environment to promote “aging term care services for older adults within a CCRC setting. at home” and combat isolation, boredom and depres- Since SHIFT receives capitated payments from Medicare sion. and Medicaid, and assumes full risk for providing health- 3. SHIFT offers the potential of coordinating and inte- care services, the incentive for the program is to manage grating the delivery of care and services. As compared the healthcare needs of the SHIFT population to maintain to hospital or physician-based coordination, which health status and residence in independent housing, to is conducted through infrequent interactions with prevent or delay disability and to manage chronic condi- the individual, the staff of a SHIFT program interacts tions, and to delay/prevent the need for costly long-term daily with residents. Problems can be caught early, care in an institutional setting. proper medication management and other follow-up The SHIFT program operates as a Type A CCRC. SHIFT, procedures will be more likely to occur, and SHIFT like all CCRCs, would seek to attract a relatively healthy staff can assist residents with complying with dietary, population, before they became frail. In addition to medication, physical activity and other guidelines. operating as a CCRC, it also operates as an insurer and Finally, and most importantly, the purely medical provider of Medicare and Medicaid health and long-term and acute care prism through which this population care benefits. As such, it assumes full risk for the health- has been traditionally viewed can be shifted to a more care, prescription drug and long-term care spending of its holistic, person-centered perspective. resident population. 4. The PACE model has demonstrated an ability to CCRCs already address the housing, meals, assisted living, “bend the frailty curve,” meaning that it is slow- nursing, therapy and psycho-social needs of its residents. ing down the onset of frailty with age. SHIFT, by A typical PACE provider would provide nursing-like ser- intervening far earlier along the curve and therefore vices, therapy, some psycho-social programs and physician operating over a longer period, should be able to dem- services, but would not offer housing. Like a PACE pro- onstrate an even stronger impact on the curve. vider, SHIFT would add physicians on staff and contract 5. The Medicaid program, by contributing to the capi- for acute care services when necessary. tated payment streams, would be capping its potential To expand the SHIFT model to allow the middle class liability, thus saving it money. In fact, an independent broader access to a CCRC environment, it is intended that study has estimated a 20 percent savings to Medicaid the Medicaid program would contribute to an individual’s under the SHIFT program over a 10 year period monthly and entrance fees on a shared basis. This contri- compared to the same population under the current bution would not change based on the individual’s care system. needs, and could be based on an individual’s income and 6. Through its design, SHIFT can provide access to the assets or perhaps only after all other resources have been vast middle class who currently are unable to access exhausted, similar to a spend-down situation. The expect- many services that are available either to upper- ed benefits of the program include the following: income or, in some cases, lower-income individuals. 1. As a combination of two proven, existing models, 7. By providing the critical mass of people within a con- SHIFT has the potential to obtain better outcomes at a centrated locality, services can be delivered in a highly lower cost. efficient and effective manner. SHIFT’s design offers

An AAHSA White Paper 20 the opportunity for the maximum amount and quality the access to, navigation through, and transitions to of services for the lowest possible cost. and from UNC Hospital; and expanding community- based preventive services for vulnerable older adults The SHIFT design needs to be tested in order to prove it through the development of a prevention clinic and can deliver improved access and better outcomes for less balance programs at the local senior center. There has money. The next steps for this program are to seek the been a specific focus on the emergency department in waiver, or legislative authority, to combine the funding in order to improve the triage and admission process for the manner described, fully design the model and desired older adults and piloting electronic communication outcomes, locate potential sites, ultimately build and with local nursing homes to test methods for sending/ operate multiple SHIFT facilities, and assess the results. receiving information. Also collaborating with a Duke Eligibility requirements for the program also need to be Health System and Durham County collaborative: determined. Currently, PACE programs cannot refuse an Healthy-In-Place (HIP) Seniors, working to address eligible client based on his or her diagnosis unless there is care coordination and prevent hospital re-admissions. a safety risk. It is not yet known if this eligibility require- ment could be extended to a CCRC platform. • Expanded falls prevention training and services to health professionals and seniors in other communities Community Connections in Orange, Chatham, and in Western North Carolina. The “Community Connections” model is an innovative, Training includes conducting screenings and making collaborative community-based service and coordination appropriate referrals for at-risk individuals, as well as model for older adults and persons with disabilities in training community exercise leaders to conduct bal- North Carolina. In Chapel Hill, Carol Woods Retirement ance exercise classes. Community has been a driving force in implementing this • Partnership with Community Care of Central model. The implementation includes the following: Carolina (CCNC). CCNC has a successful model • Coordinating community partners for the establish- that provides a medical home and case management ment of a local Community Resource Connections for services to participating Medicaid enrollees. The new Aging and Disabilities (CRC) site. The CRC is North “646 Medicare demonstration waiver” provides case Carolina’s implementation of the federal Aging and management, including hospital transition support, to Disability Resource Centers initiative funded by AoA a dual-eligible population (Medicare and Medicaid). and CMS. The focus is on the communities work- The Orange-Chatham area is an intervention site for ing together to provide seamless support (awareness, this pilot program. assistance and access) to both older adults and adults • Leading multiple workshops of the Stanford Self- with disabilities needing long-term care support. Also Management program. This evidence-based program assists with state-wide planning and expansion efforts, has been getting national attention as a key method including implementing the recently awarded Person- for managing chronic conditions and reducing hospi- Centered Hospital Discharge Planning grant from tal utilization and healthcare costs. CMS. • Collaboration with the local community health center, • Collaboration with the University of North Carolina’s Piedmont Health Services (PHS), to assist in extend- (UNC) “Futures” project. The focus is on establish- ing the service area of their rural PACE. Assisted with ing and maintaining a community partnership to improve the care of vulnerable older adults; improving

An AAHSA White Paper 21 the expansion of the county’s only adult day health support these transitions. Over 40 percent report that program. they are serving more consumers, have explored new technology, and increased healthcare in non-tradition- • Implemented a telehealth pilot through Piedmont al settings. Health Services. The first cohort of telehealth patients included 19 patients with cardiovascular disease who Section IIIG: SOURCE–A Care were enrolled in daily home remote monitoring and Management, Hospital-Based System chronic care management. Findings include: blood pressure decrease varied from one percent to six per- The Service Options Using Resources in a Community cent; weight decrease varied a total of less thanone Environment (SOURCE) program in Georgia is a percent loss to a 12.5% loss. Initial findings suggest Medicaid State Plan enhanced primary care case man- that in addition to clinical outcomes, patient empow- agement program that serves frail elderly and disabled erment and knowledge gained of disease processes has beneficiaries to improve the health outcomes of persons increased. Hospital utilization and cost data is cur- with chronic health conditions, by linking primary medi- rently being analyzed. Partners used lessons learned cal care with home and community-based services. The through this first phase of the study to implement program serves 6,900 elderly and disabled beneficiaries telehealth programs in six other community health statewide. SOURCE integrates primary medical care with centers in North Carolina. Additionally, congregate supportive services through case managers who work telehealth monitors are being piloted in local senior with the participant and their primary care physician. centers. Beneficiaries who meet eligibility criteria enroll with a SOURCE site as their primary care provider who coor- • Coordination of community engagement meetings dinates all medical and social services. The program was that have resulted in on-going community workgroups established to: to strengthen services and supports during times of transitions. Workgroups have recommended actions • Integrate primary care, specialty care and home-based for smoother transitions at UNC Hospitals, hosted care to eliminate fragmentation. education sessions on various initiatives involving • Reduce emergency room use, hospital, and nursing transitions of care at the hospital and with commu- home admissions caused by preventable medical com- nity organizations, established new programs in the plications. Emergency Department, including specially trained volunteers and the creation of new “Comfy Packs” for • Stabilize social and lifestyle factors that affect compli- older adults and adults with disabilities to help them ance, health status, and quality of life. feel more comfortable, and hosted multiple Resource Connection Fairs for older adults and their caregivers. • Ensure that current gaps in Medicaid benefits for medical and supported living services are addressed so • Due to this initiative, 85 percent of the respondents to that they do not negatively affect health outcomes and a Community Connections evaluation survey learned cost. about new programs or services, 80 percent increased connections with colleagues, 60 percent say that • Reduce the need for long-term institutional place- they have begun, or increased, their focus on transi- ment. tion issues and nearly 60 percent say that they have increased partnerships with healthcare providers to

An AAHSA White Paper 22 The case manager completes an assessment during a home Conclusion visit to enroll the person. An interdisciplinary team works While there is no one model of improving outcomes and with the older or disabled individual to meet his or her decreasing costs of care, several elements are essential to care needs. The case manager also works closely with the the design and implementation of transitional and inte- member’s primary care physician and his/her medical grated services. The transitional and integrated services director to coordinate care. The assessment provides more models must involve long-term services and support pro- extensive information to the physician about the benefi- viders, as well as primary and specialty care and acute care ciary’s social history, home environment, and functional providers. Long-term service and support (LTSS) provid- status than would normally be obtained during an initial ers have consistent interaction with the person requiring visit. Case managers contact participants at least once a the care. These providers can be instrumental in assuring month and make home visits at least once every quarter. that the patient is compliant with the plan of care devel- Carepath protocols are completed at each quarterly home oped by the hospital and physicians. LTSS providers are visit. also a good source for educating the patient and caregiver on how to care for chronic diseases, and ultimately how Based on assessment information, participants are assigned to reduce the need for acute care services. LTSS providers one of the three levels of care that meet the state’s nurs- have a long history of providing person-centered care that ing home level of care criteria. Levels one and two include is interdisciplinary. These services take a holistic approach people with substantial cognitive and/or physical impair- that addresses medications, nutrition, prevention, well- ments. Level three includes individuals who have at least ness, emotional and physical wellbeing and support one chronic condition and a need for medical monitoring, systems. We cannot wait until the Medicare and Medicaid but have less functional impairment. systems are bankrupt. Instead, we must focus on the To address risk factors related to functional capacity and models that we cover in this report that have proven to be the progression of chronic conditions, carepaths have been effective in improving outcomes and containing costs. developed and implemented for each level. Carepaths are sets of standardized outcomes for each level of care, with customized plans for each person to achieve those outcomes. Replacing traditional HCBS care plans, carepaths provide a case management structure that regularly measures the achievement of targeted key outcomes for individuals enrolled. Based on functional ability, not diagnosis, carepaths cover areas such as: keeping medical appointments, service provider performance, skin care, medication compliance, transfers, informal supports, nutrition/weight, key clinical indicators, problems with activities of daily living (ADLs) and instrumental activities of daily living (IADLs), and problem behaviors. SOURCE contractors receive a flat per member per month case management fee billed on the “CMS 1500.”

An AAHSA White Paper 23 Bibliography Medicare Payment Advisory Commission. 2007. Report to Congress: Promoting Greater Efficiency in Medicare. American Association of Homes and Services for the Aging. 2006. Financing Long-Term Care: A Framework for America. Mollica, R. L. 2003. Care Coordination for People with Chronic Conditions. National Academy for State Health Policy. Boult, C. et al. “Early Effects of ‘Guided Care’ on the Quality of Health for Multimorbid Older Persons: A Cluster-Randomized Controlled Myers and Stauffer LC. 2006. Final Report on SOURCE Program Cost Study.” Journal of Gerontology: Med. Sci., 63A(3)321-327. Effectiveness. Prepared for the Georgia Department of Community Services. Burke, J.D., Taylor, & Rosenbaum, J.D., Sara. “Accountable Care Organizations: Implications National Commission for Quality Long-Term Care. 2007. From Isolation to Integration. Recommendations to Improve Quality in Long- for Antitrust Policy.” March 2010. Online at: http://www.rwjf.org/files/ Term Care. research/57509.pdf. Naylor, M. 2004. “Transitional Care for Older Adults: A Cost-Effective Centers for Medicare and Medicaid Services. “Medicare Health Support Model.” LDI Issue Brief, 9(6). Overview.” Online at: http://www.cms.hhs.gov/CCIP./. Office of Sen. Ron Wyden. 2008. “Wyden, Markey Introduce Coleman, E. et al. (n.d.). University of Colorado Health Sciences Center Independence at Home Act.” Online at: http://wyden.senate.gov/news- Division of Healthcare Policy and Research. Online at http://www.care- room/record.cfm?id=303719. transitions.org/ Partnership for Strong Communities. “The History of Supportive Congressional Research Service. 2006. Integrating Medicare and Housing in Connecticut.” Online at: http://www.ctpartnershiphous- Medicaid Services through Managed Care. ing.com/index.php?option=com_content&task=view&id=697&Item id=117. Devers, Kelly and Berenson, Robert. “Can Accountable Care Organizations Improve the Value of Healthcare by Solving the Cost and Stanford Self-Management Programs. Online at: http://patienteduca- Quality Quandaries?” October 2009. Online at: http://www.rwjf.org/ tion.stanford.edu/programs/. files/research/acobrieffinal.pdf. The Hospitalists, April 2010. Online at: http://www.the-hospitalist.org/ Fischer, Elliott S., Staiger, Douglas O., Bynum, Julie P.W.; and Gottlieb, details/article/590291/Transition_Expansion.html. Daniel J. Creating Accountable Care Organizations: The Extended Hospital Medical Staff,” Health Affairs, 26, no. 1 w44-w57. 2007. Online Tobin, J. “Continuity Assessment Record and Evaluation.” at: http://content.healthaffairs.org/cgi/content/abstract/26/1/w44. PowerPoint presentation for the Centers for Medicare and Medicaid Services. Online at: http://www.cfmc.org/value/files/ Health Affairs. Accountable Care Organizations. Aug. 13, 2010. Online TransitionalCareLearningSess-05-15-08jt.pdf. at: www.healthaffairs.org. Tritz, Karen. 2006. Integrating Medicare and Medicaid Services through Johns Hopkins Bloomberg School of Public Health. Online at: http:// Managed Care. Congressional Research Service. www.guidedcare.org/. Verdier, J.D., et al. “Do We Know if Medicare Advantage SNPs are Kuhmerker, K. and T. Hartman. 2007. Pay-For-Performance in State Special?” Mathematica Policy Research, Inc. for the Henry J. Kaiser Medicaid Programs: A Survey of State Medicaid Directors and Programs. Family Foundation, Jan. 2008. The Commonwealth Fund/ IPRO.

AAHSA Staff Liaisons AAHSA Also Appreciates the Contributions of the Following Individuals: Larry Minnix President & Chief Executive Officer Katie Sloan Chief Operations Officer & Senior Vice-President of Member Services Morgan Gable Policy Analyst Robyn Stone Executive Director, Institute for the Future of Aging Services Peter Notarstefano Director, Home and Community-Based Services Doug Pace Executive Director, Long-Term Quality Alliance Susan Weiss Senior Vice-President, Advocacy

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