Presentation at National Hospice and Palliative Care Organization's 26th Annual Management & Leadership Conference, April 2011. One of the presenters is Kyle R. Allen, DO, AGSF, Chief, Division of Geriatric Medicine and Medical Director of Post Acute & Senior Services for Summa Health System.

2. Strategic Options for Hospice and Palliative Care in the Era of Accountable Care Organizations NHPCO 26th Annual Management & Leadership Conference April 2011 1

3. Presenters Jade Gong, MBA, RN Vice President, Strategic Initiatives Health Dimensions Group 4012 Nelly Custis Drive, Arlington, VA 22207 703-243-7391; jadeg@hdgi1.com Kyle R. Allen, DO, AGSF Chief, Division of Geriatric Medicine Medical Director Post Acute & Senior Services Summa Health System 75 Arch Street, Ste G1, Akron, OH 44303 330-375-3747; allenk@summahealth.org Jane Gorwin, RN, BSN, LNC, MA Senior Home Health and Hospice Consultant Health Dimensions Group 4400 Baker Rd, Ste 100, Minneapolis, MN 55343 760-250-4558; janeg@hdgi1.com 2

4. Topics Health care reform and its impact on post-acute and aging services providers Strategies for hospice and palliative care providers PEACE model of care PACE as an accountable care organization (ACO) model 3

6. Bundled Payment

8. Why Post-Acute Is Key to Managing Health Care Costs 6

9. Post-Acute Payments by Venue and Condition 7 In ACO-land, expect greater use of subacute skilled nursing and home health Note: Data are preliminary and subject to change. Numbers reflect standardized payment rates and therefore do not reflect provider-specific adjustments such as the area wage index or DSH payment adjustments. Spending captures payments for all PAC services that occur within 30 days of discharge from the hospital. Source: MedPAC analysis of 5% Medicare claims files 2004 to 2006.

11. Value-based reimbursement

13. Medical homes

14. Health information exchange8

15. How ACOs Provide Accountable Care in a New Delivery System Capacity to deliver continuum of care, grounded in strong primary care and minimal use of high-cost institutional settings Payment rewards slower cost growth so long as combined with improvements in quality Reliable measures of a person’s health assure that savings are achievedthrough improvements in care 9

17. Accountable for all Medicare Part A and Part B service

18. Requires integrated provider network; successful chronic care management; comprehensive home-based services

20. Skilled nursing

21. Home health

22. Hospice

23. Geriatric care management

24. Non-institutional home-based services

25. Prevention and wellness programs

26. Medical Group(s)

27. Community MDs

28. Medical Home10

29. Medicare ACOs in 2012, But Many ACO Demonstrations Now 11 3 Medicare Pilot Sites Many Private Payer Pilots Roanoke, VA Medica and Insurers Louisville, KY Tucson, AZ Torrance, CA

31. Networks of individual practices

32. Partnerships or JV arrangements between hospitals and ACO professionals

33. Hospitals employing ACO professionals

35. Physician assistant, nurse practitioner, or clinical nurse specialist

36. Certified registered nurse anesthetist

37. Certified nurse-midwife

38. Clinical social worker

39. Clinical psychologist

41. New Payment Model for Medicare ACOs: Shared Savings Current per-capita spending for assigned patients determined from claims for past three years Spending target is determined (Medicare) If actual spending lower than target, savings are shared IF quality targets are also achieved 14 ACO Launched Projected Target Shared Savings Actual 14 Adapted from Brookings Institute

42. Sample ACO Calculation 15 An organization must meet quality standards AND achieve cost savings to earn bonus payments * Actual costs for “assigned” population are less than pre-set expected costs based on risk-adjusted trends ** PGP demonstration gave groups 80% of savings; actual split for ACOs to be determined

44. Pendingre-admission penaltiesPartner with other providers to enhance yourpost-acute andhome care continuum Partner with like providers to create one-stop chronic care management Strategy includes care transitions management and electronic health record

47. How Do Palliative and Hospice CareFit into an ACO Model? Laying the foundation for a palliative care framework first 19

48. How Do Palliative and Hospice CareFit into an ACO Model? (continued) 20

49. What Needs to Change? The basic way we work with patients, especially in one of these three categories: Chronic Disease Management Need to better identify where a patient is within this trajectory Enhance acute to community-based transitional care coordination Interventional Palliation Educate/enlighten patient and family earlier Provide options for patient/family choice Hospice Care Marketing strategy and partnerships with hospitals and PCP 21

50. What Do ACOs Want from Post-Acute and Aging Services Providers? Not likely to be a partner, with “skin in the game”, but rather a contractor ACOs will want few PAC provider-contractors who: √ Can demonstrate value (quality and cost reductions) with credible data  Few 30-day hospital readmissions  High volume of discharges to home √ Have evidence-based clinical programs for most common SNF-HHA discharges and a care transitions program between venues √Have facilities/services that are geographically convenient to primary care physicians and hospitals √ Already have positive relationship with hospitals and PCPs √ Willing and able to be part of health information exchange 22

51. Hospice: Well Positioned for the Future Aging demographics – baby boomers Chronic disease “explosion” Key offenders: Congestive Heart Failure Diabetes Chronic Obstructive Pulmonary Disorder Pneumonia Parkinson’s – ALS – Dementias Depression 23

52. Not-for-Profit Accountable Care Readiness Strategy: Aging Services Provider Partnerships 24 Create a not-for-profit consortium within a market that has more value than any organization individually Benefits: One-stop shopping for hospitals and ACOs Benchmarks for hospital readmissionsand ongoing comparison Post-acute provider partnerships in geographic areas creating care continuum with standardized protocols Care management projects Bundling experiments with Medicare Advantage Plans as we learn to take risks Apply for grants for demonstration projects

54. Cost reductions for post-acute episode of care

55. Care coordination across the continuum

56. Chronic care management to reduce ED visits and hospitalizations

57. Electronic information exchange

58. Ability to share payment risk based on outcomes25

59. Define Your Services: What are You Providing Within the Continuum? Palliative Care: interventional and comfort care focus Palliative care in–patient hospital versus home health Hospice Care: comfort care and quality of life focus Routine hospice care Respite Continuous care General in patient 26

60. Overarching Strategy of Why You Will Benefit an ACO Ability to reduce 30-day (+) hospital readmissions Ability to reduce emergency/urgent care visits Reduce hospital length of stay Potentially decrease in-patient hospital mortality rates 27 KNOW YOUR DATA AND SHARE IT!

61. Critical Elements for a Successful Strategy Implementation Evidence-based practice (interventional PC and hospice) Use of aligned, care protocols Patient/family centered—self-care management driven Coaching: motivational interviewing skills Patient/Family self goal-setting Medication awareness (PHR) Self symptom management and interventions 28

62. Critical Elements for Successful Strategy An integrated care management and health system navigator approach Effective electronic information exchange From provider to provider Patient/family to provider (tele-health, bio-sensory technology, video-audio interface) Real-time data management decision-making 29

63. What are Some of the Current Challenges? Current fiscal realities (shrinking margins) Hospitals Home Health Hospice Regulations and future Medicare payment models are always “behind” Hospice: limited to 6-month end-of-life prognosis Palliative care: not officially recognized No specific reimbursement for care management models…..yet 30

64. More Challenges Need for highly sophisticated data management information systems that will: Enhance traditional quality care indicators (pain management, satisfaction surveys post-death) Provide predictive statistical modeling as relates to primary diagnoses and co-morbid conditions Help to identify patients’ clinical and social needs within their trajectory (chronic disease management, interventional palliation, hospice) 31

65. Next Steps to Move Your Strategy Forward Evaluate your current services Do you provide what your hospital(s) and PCP(s) need? Do you collect the right data? Research your most likely ACO partners What are their specific needs? Get their data: mortality rates, lengths of stay, top chronic diseases causing the readmissions 32

66. Moving Your Strategy Forward Develop your presentation to meet with potential ACO partners: hospitals and PCPs Be specific with your data to show how YOU will be essential to their accountable care organization Explore current funding opportunities: Shared risk ventures with Medicare Advantage plans Grants Demonstration projects Be proactive to get a “seat at thetable” and start now! 33

67. If everything seems under control, you're just not going fast enough 34 Mario Andretti.

68. PEACE TRIAL Promoting Effective Advanced Care for Elders Kyle R. Allen, DO* Steven Radwany, MD* Susan Hazelett, MS, RN* Denise Ertle, MSN, RN, CNS* * Susan Fosnight, RPh, CGP, BCPS* Pamela Moore, PharmD, BCPS* Patricia Purcell, MSN, RN, CNS* * * Barbara Palmisano, MA * * * * Ruth Ludwick, PhD, RN.C, CNS* * * * * * Summa Health System, Health Services Research and Education Institute * * Area Agency on Aging 10B, Inc.* * * The University of Akron * * * * Northeastern Ohio Universities Colleges of Medicine and Pharmacy * * * * * Summa Affiliate, Robinson Memorial Hospital The PEACE Trial is supported by The National Palliative Care Research Center & the Summa Foundation Area Agency on Aging, 10B, Inc. | Summa Health System | NEOUCOM Kent State University | The University of Akron

69. Key Points A National Palliative Care Research Center-funded trial ($154,000 over 2 years) Collaboration between The University of Akron, Kent State University, Northeastern Ohio Universities Colleges of Medicine and Pharmacy, the Area Agency on Aging 10B Inc., and Summa Health System A randomized controlled pilot study A palliative care case management intervention for PASSPORT consumers Intervention involves collaborative care between a hospital-based interdisciplinary team, the Area Agency on Aging, and the consumer’s PCP 36

70. The S.A.G.E. Project(Summa Health System/Area Agency on Aging, 10B/Geriatric Evaluation Project: A Successful Health Collaborative(Est. 1995) Improving Care through Collaboration: Integration of the Aging Network and Acute and Post Acute Medical Care Services 37

72. A community-based Area Agency on Aging 38

73. The SAGE Project A 15-year collaboration partnership Multiple initiatives, a “cast of thousands”, well maybe 100s, but you get the point Common goal to improve the health, well being and functional status of Akron region frail older adult population Identified major gaps in the continuum and care processes from each partner Searched and defined mutual benefits Shared mutual threats and concerns Built trust Grew and multiplied to other regional systems Communication, communication, communication Vision, Vision, Vision, Vision 39

74. Area Agency on Aging Programs Mission: To provide older adults and their caregivers long-term care choices, consumer protection and education so they can achieve the highest possible quality of life. Aging Resource Center PASSPORT Home Care Medicaid Waiver Assisted Living Medicaid Waiver Community Services Division Care Coordination Alzheimer’s Respite Program Family Caregiver Support Elder Rights Division 40

75. Who were the partners?Summa Health System Geriatric Medicine Department Summa Akron City Hospital Summa St. Thomas Hospital 6 Hospital System 2,027 licensed beds 61,800 admissions Level 1 Trauma 113,059 ED visits Community Locations 4 outpatient health centers Wellness Institute – medically-based fitness Health Plan 110,000 Covered Lives 16,000 Medicare Risk HMO Major Teaching Residency and Fellowship Program Post Acute/Senior Service Line 10 Certified Geriatricians 12 Geriatric Certified APNs Continuum of Care Acute Care/Acute Rehab/ LTAC/ SNF Beds Home Care/ Hospice/ Home Infusion/ HME SummaCare, Inc. Summa Western Reserve Hospital 41

76. Summa’sInstitute for Seniors and Post-Acute Care 42

78. Advance care planning and palliative care/geriatric syndrome management for low income seniors

79. Nurse care manager activation of client

80. Collaboration between a hospital-based interdisciplinary team, Area Agency on Aging, and PCP

81. Integration of acute and long-term care

85. Care management and services for long-term care

86. Limited interaction with PCP

87. Addresses functional abilities/geriatric syndromes but challenged with high risk enrollees with multiple chronic illnesses

88. AD-LIFE trial is supported by the Agency for Healthcare Research and Quality Grant # R01 HS014539. PEACE is funded by the National Palliative Care Research Center. Both are supported by the Summa Foundation.

89. Bridge to Home is funded by SummaCare.43

91. Health Care Utilization Experience for Patients with Chronic Conditions: Current Health Care System Community-dwelling chronically ill patient with poor symptom control and coordination of care whose advance care wishes are rarely documented Hospitalization prompting advance care decisions (often by the family) Exacerbation of chronic illness 45

92. Palliative Care and Advance Care Planning Independent Management Hospice Advance Care Planning Symptom Management Disease Management Death Diagnosis 46

93. Patient Centered Care 47 Well Older Adults Cancer AIDS Gait Disorders Cancer (<65) Stroke Preventive care Genetic/ Developmental Disorders Advanced Organ Failure Palliative Care Geriatrics Stable chronic dx Chronic Critical Illness Geriatric syndromes Pediatric Oncology Frailty Peri-operative care Cystic Fibrosis Dementia Osteoporosis TBI Morrison, S . National Palliative Care Research Center

94. Target Population for the PEACE Pilot Study New PASSPORT enrollees >60 years old with one of the following diseases and the corresponding level of severity will be eligible for inclusion: CHF and being actively treated (AHA class C) COPD and on home O2 or nebulizer treatments Diabetes with renal disease, neuropathy, visual problems, or CAD End-stage liver disease, cirrhosis Cancer (active, not history of) except skin cancer Renal disease on dialysis ALS with history of aspiration Pulmonary hypertension Parkinson’s disease (stages 3 and 4) 48

95. Enrollment RN assessors from the AAoA will screen consumers at the time of their initial PASSPORT assessment RN assessor will obtain HIPAA release Research nurse will obtain consent and obtain baseline measures Consumers will be randomized to usual care or the intervention group 49

96. Intervention Each Care Manager will have approximately 10 consumers Care Manager will make 2 home visits centered on symptom assessment & advance care planning Care Manager will take her assessment findings to an interdisciplinary team Team produces recommendations for consumer & PCP Care Manager accompanies consumer to 1 PCP visit to assist consumer in discussing advance care goals with PCP Care Manager & Palliative Care Nurse supervisor make another home visit to begin implementation of plan of care Care Manager follows-up with consumer monthly for 1 yr to assure team recommendations are implemented PEACE Intervention 50

97. OutcomesMeasured at 3, 6, 9 and 12 months 51

98. Challenges Getting buy-in from case managers Education and knowledge gaps Changing culture of the AAA Needing to get more top-down support for the project so AAA CM supported for the project Not over “medicalizing” the care plans 52

99. Successes Strong working relationship and commitment by the AAoA A team that has gone from forming to storming, not yet norming Culture sensitivity and knowledge between aging network and acute care sector—“becoming bilingual” Outgrowths of other educational projects, additional funding for PC research, and bridging the community network and acute sector 53

100. Additional PEACE Related Projects A survey of knowledge and attitudes about ACP and PC sent to all area PCPs. Funded by the Summa Foundation. A statewide survey of all care managers at all AAoA that will examine knowledge and attitudes regarding ACP and PC. Funded by Northeastern Ohio Universities Colleges of Medicine and Pharmacy. An educational program to teach AAoA care managers how to bring PC upstream in the disease process. Funded by the First Merit Foundation. 54

101. PACE as an ACO Model of Care Jade Gong, MBA, RN Health Dimensions Group 55

102. Comprehensive Services Integrates preventive, acute, and long-term care services All Medicare and Medicaid services, plus community long-term care services No benefit limitations, co-payments,or deductibles PACE is the only fully capitated and integrated Medicare and Medicaid program to serve frail nursing home eligibles 56

103. PACE Eligibility Criteria 55 years of age or older Live in a PACE service area Be certified as eligible to receivea nursing home level of care Be able to live safely in thecommunity at point of enrollment 57

104. PACE Enrollees Snapshot 58

105. PACE Nationally 79 PACE organizations and growing 31 states 20,000 PACEparticipants 100 to 2,000participantsper program 59

106. Social Services Pharmacy Home Care Nutrition Activities Personal Care Primary Care Transportation OT/PT Well-functioning IDT Key to PACE Success 60

107. PACE Network 61 PACE Center PACE Team

108. PACE Payment Sources Payment features are unique Capitated payment system—per member per month (PMPM) Combines funding from multiple payor sources to meet all participant needs 62

109. Integrated Financing 63

110. Place of Death in PACE 53% Older Americans 20% 64

111. Survival in PACE South Carolina Two counties PACE group same baseline risk as NH group PACE group higher baseline risk than Waiver group 65

112. PACE Core Competencies Provider-based model Tightly controlled care management and utilization systems Serves a nursing home-eligible population in the community when enrolled Good health care outcomes, high enrollee satisfaction, and low disenrollment rates Established existing program with a proven track record 66

113. Opportunities for Hospice and PACE Collaboration in the Delivery of Person-Centered Care 67

114. Exploring Common Ground:PACE and Hospice Patient centered Holistic approach to care Utilizes interdisciplinary teams Supports caregivers Utilizes managed care efficiency Receives capitated payment (per diem or per month) 68

115. Why Should Hospice Develop PACE Programs? Meet community needs with broader care options for frail seniors at the end of life Build upon community awareness of hospice Draw upon greater stability of multiple revenue streams Greater efficiency through shared allocation of administrative expenses 69

116. PACE with Hospice Opportunities for Collaboration Each provider can focus on providingpatient-centered care Some hospice referrals may be more appropriatefor PACE Some PACE referrals may be more appropriatefor hospice PACE can utilize hospice expertise through contracting: Pain and symptom consultation/pain management Use of hospice interdisciplinary team (IDT) Training in end-of-life care Inpatient hospice facility if needed by participant 70