Taking BeTTer Care - Alliance of Community Health Plans

Executive Summary

Taking Better Care: Supporting Well-Being for an Aging Population

survey of older people with multiple chronic conditions, 76 percent ranked independence as I nthea 2011 most important health outcome from treatment, followed by pain and symptom relief. 1

“We think our job is to ensure health and survival,” writes surgeon and author Atul Gawande, M.D. “But really it is larger than that. It is to enable well-being.”2 Over the next 25 years, the population of Americans aged 65 and older will double to about 72 million, with roughly 10,000 Americans turning 65 every day from 2011-2031.3 Members of the Alliance of Community Health Plans are caring for this growing population, realizing that their needs extend far beyond clinical care. ACHP member plans are working to keep frailer seniors out of the hospital and where they feel most comfortable — at home, in an assisted-care environment, or in some sort of combination — so their final years may be independent, dignified and personally fulfilling. Geisinger Health Plan’s (Danville, Pennsylvania) Medically Complex Model uses care teams with a nurse and a community health assistant to treat elderly patients with complex conditions. Each team visits patients in hospitals or nursing homes to introduce itself and arrange post-discharge home visits. During home visits, the team assesses overall health, nutritional support, patients’ medication management needs, safety in the home environment and the level of support patients receive at home. The team, which can also involve a pharmacist or social worker when needed, aims to help patients continue to live at home with the right resources and manage their health conditions proactively to avoid frequent visits to the emergency department.

» KEY SUCCESSES: During the nine-month pilot, care teams closed an average of 14.8 gaps in care, such as medication adherence, and 2.8 safety-related gaps per patient, such as hazards in the home.

Kaiser Permanente’s Proactive Assessment of Total Health & Wellness to Add Active Years (PATHWAAY) program is designed to help patients and physicians find ways to discuss topics such as cognitive impairment or urinary incontinence. These and other key topics are often left out of patient-physician conversations, leading patients to believe they aren’t issues that could be addressed. PATHWAAY routinely screens members to identify risks for falls, urinary incontinence, malnutrition,

Through the programs described in this report, ACHP members are: 1. Supporting seniors beyond clinical care in all aspects of their life. 2. Keeping seniors out of the hospital and where they are most comfortable, so their final years may be independent, dignified and personally fulfilling. 3. Lowering costs so health care can be more affordable.

pain, frailty and mood disorders, and triggers the creation of a comprehensive care delivery plan.

» KEY SUCCESSES: More than 70 percent of members

who completed the Total Health Assessment as part of their Annual Wellness Visit said they are more aware of and better understand actions they can take to reduce their health risks. Presbyterian Healthcare Services’ (Albuquerque, New Mexico) Hospital at Home program allows patients who meet the criteria for an inpatient level of care and

A Medically Complex Patient Story: Before and After “Mary” is 88, with a history of heart failure, COPD, kidney disease and atrial fibrillation. She lives alone, is hard of hearing, does not drive, eats poorly and struggles to care for herself. After visiting Mary, the Geisinger Medically Complex Medical Home team arranged for home-delivered meals, transportation services and some in-home care. They also taught her about self-care. The program made an important difference in the quality of Mary’s life: In the nine months before she enrolled in the program, Mary had two urgent hospital admissions, one skilled nursing facility (SNF) stay and one emergency room (ER) visit for heart failure. Eight months post-enrollment she had no inpatient admissions or SNF stays and one ER visit.

who would traditionally be admitted to the hospital to receive care at home. Patients receive daily visits from an M.D. or nurse practitioner and one to two visits daily by a nurse. Early findings from the national Hospital at Home program found patients were better able to resume activities of daily living after discharge compared to hospitalized patients.4 Upon discharge from Hospital at Home, patients continue to be followed by the same provider through Presbyterian’s House Calls program if they are too frail to transition back to their primary care physician.

» KEY SUCCESSES: Results include a shorter average

length of stay in Hospital at Home as compared to an inpatient stay (3.3 days vs. 4.5 days) and lower 30-day readmission rate of 3.2 percent vs. 9 percent nationally. Priority Health (Grand Rapids, Michigan) teamed with five local non-profit skilled nursing facilities (SNF) and a local ambulance company to create the Tandem365 program. Emergency medical technicians check on patients in their homes and provide some treatment under the guidance of a medical director. Social workers, nurses and community organizations each play a role, accompanying patients to primary care physician appointments, taking them shopping and providing companionship. Volunteers from area church groups offer spiritual camaraderie.

» KEY SUCCESSES: Results include a 38 percent decrease in inpatient stays and a 52 percent drop in emergency department visits. Fallon Health (Worcester, Massachusetts) offers two coordinated care solutions that help older individuals who are eligible for Medicare, Medicaid or both remain living independently in the community. Summit ElderCare®, a PACE program, offers participants interdisciplinary care, socialization, recreation, counseling, rehabilitation therapy and meals at PACE adult day health centers, as well as home care, transportation and caregiver support. NaviCare®, a dual-eligible special needs plan, emerged from Fallon’s successful track record with Summit ElderCare. NaviCare enrollees first receive a comprehensive assessment by health care professionals in their home. The results are reviewed with the enrollee’s primary care physician and a care plan is shared with the enrollee. The care team and a “navigator” continue to partner with the primary care physician, enrollee and caregivers.

» KEY SUCCESSES: NaviCare data show enrollee satisfaction rates at 98 percent consistently since the inception of the program. Summit ElderCare PACE participants are also highly satisfied (97.5 percent).

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CHP member plans understand that improving health and well-being requires addressing the full spectrum of social and medical needs of a person in his or her twilight years. It is not just about addressing care in the last stage of life and it is not just about caring for people only once they become frail. Allocating resources to those seniors who need it is about developing individual approaches to improving health for an entire population.

1 Terri R. Fried, M.D., et al. (2011). Health Outcome Prioritization as a Tool for Decision Making Among Older Persons With Multiple Chronic Conditions. JAMA Internal Medicine, 171(20):1856-1858. doi:10.1001/archinternmed.2011.424. 2 Gawande, A. (2014). Being mortal: medicine and what matters in the end. New York, NY: Metropolitan Books, Henry Holt and Company LLC. 3 Centers for Disease Control and Prevention (2013). The State of Aging & Health In America 2013. Retrieved from Centers for Disease Control and Prevention website: http://www. cdc.gov/features/agingandhealth/state_of_aging_and_health_in_america_2013.pdf 4 Leff, B. et al. (2009). Comparison of functional outcomes associated with hospital at home care and traditional acute hospital care. Journal of the American Geriatric Association, 57:273-278. Retrieved from http://www.hospitalathome.org/files/HaH%20JAGS%20Functional%20Outcomes.pdf

Case Study

Priority Health's Tandem365 Program To care for many of its Medicare members, Priority Health has partnered with Tandem365, an organization that delivers a comprehensive menu of health care and social services to at-risk seniors in their homes.

Background: Collaboration of Care Priority Health wanted to provide more services than it could through its transitional home-care model. It chose to focus on better serving a specific kind of patient: seniors with multiple health care and social needs who find traditional ambulatory care impractical. Priority Health collaborated with five local non-profit

Tandem 365: At a Glance • Created to improve health and quality of life by keeping seniors at home whenever possible. • Focuses especially on patients with social burdens such as isolation, poverty, frailty and lack of transportation. • Delivers care and services at home that are not typically reimbursed. • A behavioral health component marks the difference from more traditional home-based care. • Meant to be a source of life-long support rather than a transitional care program.

skilled nursing facilities (SNF) that provide a range of levels of care and living options. Like Priority Health, the SNFs wanted to move more care delivery into patients’ homes. The SNFs brought a local ambulance company into the conversations to explore whether or how emergency medical technicians (EMT) could use their specialized skills to provide some services in the home. This creative thinking required obtaining approval from the state of Michigan for EMTs to coordinate some in-home care with Priority Health’s medical directors, since EMTs in the state are normally required to transport patients they treat to an emergency room or call in their patient encounters to an ER physician. The SNFs and the ambulance companies then formed Tandem365. Tandem365 developed an integrated, athome care model combining medical, behavioral and social health care that focuses on patients with a burden of illness whose psychosocial and financial challenges make them unable to access traditional ambulatory care. It currently serves about 150 patients, focusing on alleviating isolation, frailty, transportation issues and results of poverty, as well as illness.

how the program works: Creating a Life Plan When Priority Health refers patients to Tandem365, a nurse and social worker partner with the primary care physician to assess the patient’s medical, behavioral and social needs. The goal is to create a “life plan” through

Utilization and Costs Before and After Tandem365

which Tandem365 can support patients as long as they wish, rather than during a short time of acute need. The referral process is proactive: Priority Health staff members work in the SNFs to help with discharge planning, which enables them to identify patients for ongoing support at home through Tandem365. Priority Health’s care managers use claims analytics data to identify those patients whose burden of disease and high use of services indicate they may benefit from the program. The Tandem365 team provides direct care to patients in their home and also coordinates additional support from community or volunteer organizations, such as meal delivery, transportation to doctor’s appointments, chore services, adult day care or personal aides. The Tandem365 nurse or social worker accompanies

the patient to doctor’s appointments or meets him or her in the emergency department, to provide care management and coordination.

results: Utilization Dropping Priority Health compared claims data for 53 members before and after they enrolled in Tandem365. The data show: •

A 38 percent decrease in inpatient stays.

• A 52 percent drop in emergency department visits. • 46 percent fewer specialty visits. • A 35 percent reduction in the total cost of care.

A Patient Story: Before and After “Sandy” was a homeless woman living out of her car who suffered from severe migraine headaches. A Tandem365 team met with her at her car. They prescribed her pain medications and connected her with a social worker. Within a week, she had secured a permanent residence and was quoted as saying that she had never been cared for in this way.

ACHP Case Study: Priority Health's Tandem365 Program

Case Study

Kaiser Permanente's PATHWAAY Program Thinking beyond traditional clinical screenings helps Kaiser Permanente identify patient needs that might otherwise be overlooked.

background: Getting Better Information from Patients Several years ago Kaiser Permanente (KP) began to look at ways to get more information from Medicare members about how they perceive their own health. The work was built, in part, on research showing that some topics such as cognitive impairment or urinary incontinence may not come up naturally in conversations between older patients and their doctors, often because patients don’t think they are issues that can be addressed. But Kaiser Permanente wanted an instrument that would yield broader and more specific information to help clinicians identify areas of concern and prepare customized care plans for older patients, with the goal of helping them maintain their independence as long as possible. Using information from this survey instrument, KP’s Colorado region started a clinical program called PATHWAAY — Proactive Assessment of Total Health & Wellness to Add Active Years — which routinely screens members to identify their risks for falls, urinary incontinence, malnutrition, pain, frailty and mood disorders, and triggers proactive workflows and the creation of a comprehensive care delivery plan.

How the program works: Personal Care Plans Based on Detailed Information Medicare members complete a comprehensive Total

Health Assessment (THA) and, based on their responses, individuals receive a proactive outreach call from a registered nurse prior to their doctor appointment. The nurse gathers more information and discusses risks and concerns in greater detail. Then, in collaboration with the primary care physician, the nurse creates a Personal Prevention Plan (PPP) that outlines steps to mitigate the risks, such as taking a balance class if falling is a risk. At the appointment, the doctor performs a physical exam and reviews the THA and PPP together with the patient,

PATHWAAY: At a Glance • Medicare members complete a comprehensive THA by phone or email prior to annual wellness visit. • Nurse assesses patient’s risks and, with the primary care physician (PCP) and patient, creates a prevention plan to pre-address issues and prepare for doctor visit. • PCP reviews THA and prevention plan with patient at visit, addressing risks and concerns that the THA reveals. • Both providers and patients believe the THA prompts conversations they might not otherwise have.

confirming or updating concerns and plans to address them. Each patient receives an after-visit summary and all the information from the THA, PPP and visit are entered into his or her electronic medical record.

Results: Important Conversation Starters Kaiser Permanente Colorado reports that about 67 percent of completed THAs reveal at least one positive trigger for a risk intervention, with the two most common being falls and urinary incontinence. Additionally, the program’s leaders believe that the THA is having an effect on the treatment of urinary incontinence, a subject that can be difficult for both patients and providers to bring up. Putting it on the list of concerns alongside issues such as nutrition and mobility normalizes it as an appropriate area of concern. In a telephone survey of 254 KP Colorado Medicare members who had completed the program within the previous year, more than 70 percent said they reported issues through the THA that they might not have addressed during a regular visit with their primary

Patient Story: Before and After “Beth” triggered positive for frailty on her THA. She was losing weight, falling in her home, isolated and depressed. Through the THA the nurse learned Beth wasn’t eating because she couldn’t chew. And she couldn’t chew because she didn’t have teeth. Everything was flowing from there: Her poor nutrition led to frailty, which triggered her falls, and her fear of falling led to isolation. Her Kaiser team was able to connect to resources for her dentures and set her on the path to improved health and happiness.

care provider. In an informal survey of physicians, a majority said the THA prompted them to discuss issues with patients that they might not have raised otherwise. Patients said they used to believe that if the doctor didn’t bring up a specific issue, it must not be important.

"PATHWAAY for Seniors" Model — The Workflow

ACHP Case Study: Kaiser Permanente's PATHWAAY Program

Case Study

Geisinger Health Plan's Medically Complex Medical Home Program A program involving home visits by health care professionals is a challenge for a rural organization such as Geisinger Health Plan. But through judicious use of care providers, each working at the top of his or her training, the health plan has hit on a promising formula that is improving care. How the program works: Team-Based Care in the Patient's Home

community health assistant — a trained, non-licensed health worker.

Geisinger Health Plan’s nine-month pilot identified patients who were appropriate for the Medically Complex Model (see sidebar) through referrals and utilization data, seeking the highest-risk patients based on frequent visits to the emergency department or inpatient admissions and readmissions. The care team Geisinger designed for this special population of complex elderly patients is a nurse case manager and a

When a patient is identified, the team members visit him or her in the hospital or nursing facility to introduce themselves and make arrangements to visit at home within 48 hours of discharge.

Medically Complex Medical Home: At a Glance • High-risk medically complex patients are managed and monitored by a two-person care team of a nurse case manager and community health assistant. • The team oversees the transition home from the hospital or skilled nursing facility, visits the home and creates a care plan that is easily understood and implemented by the patient. • The team ensures follow-up care and appointments and arranges for support services. • The patient’s care is handed back to the Medical Home when appropriate.

Geisinger has determined that it is crucial to identify gaps in care and then work to fill them. The team looks for anything that may be an impediment to managing the patient’s health conditions, including clinical issues like medication adherence, social issues like the ability to prepare food at home and safety issues like wires or throw rugs that could lead to falls. Medication management is particularly emphasized as medication mishaps are often a cause of readmission. The care team also reviews with the patient a customized care plan called a Self-Management Action Plan. This plan includes details about symptoms the patient should watch and easily understood actions the patient can take on his or her own depending on the symptoms observed. The typical length of stay in the program before patients are handed back to the patient-centered medical home team is three to six months, although some patients remain in the program indefinitely if they continue to be high-risk. Hospice is called in as early as possible in cases where it is appropriate, and the team continues to manage the patient’s care until his or her death. In some cases, patients have listed care team members in their obituary, recognizing them as a part of the person’s family and a key element of the support structure for the last chapter of life.

Results: More Complete Care, Lower Costs The program has resulted in an approximately 20 percent, $1000 per-member-per-month, cost reduction for those in the program, largely from a significant decrease in the number of times a member needed to visit the emergency department or be admitted to the hospital. During the nine-month pilot, a redesigned care team managed 75 medically complex patients. Program leaders have tracked how well the program has addressed gaps in care and what the effect has been on utilization and costs. Over the nine-month period they closed: • 433 gaps in care related to plan of care optimization (standards of care gaps). • 201 gaps in care related to safety. • 21 gaps in end-of-life planning. • 416 gaps related to medication management including medication omissions and medication adherence.

A Medically Complex Patient Story: Before and After “Mary” is 88, with a history of heart failure, COPD, kidney disease and atrial fibrillation. She lives alone, is hard of hearing, does not drive, eats poorly and struggles to care for herself. After visiting Mary, the Geisinger Medically Complex Medical Home team arranged for home-delivered meals, transportation services and some in-home care. They also taught her about self-care. The program made an important difference in the quality of Mary’s life: In the nine months before she enrolled in the program, Mary had two urgent hospital admissions, one skilled nursing facility (SNF) stay and one emergency room (ER) visit for heart failure. In the first eight months of her enrollment, she had no inpatient admissions or SNF stays and one ER visit.

A member of the Geisinger care team talks with a program enrollee about her medications. ACHP Case Study: Geisinger Health Plan's Medically Complex Medical Home Program

Case Study

Presbyterian Healthcare Services' Hospital at Home Program Given the choice, most patients would rather receive care at home than in the hospital. Through Hospital at Home, Presbyterian Healthcare Services is meeting that wish for many patients, and producing better outcomes. background: Moving Home Care to the Next Level Through Presbyterian Healthcare Services’ Hospital at Home program, a team of clinicians offers in-home skilled multidisciplinary care in the four-county area surrounding Albuquerque and parts of Santa Fe County. In collaboration with experts from Johns Hopkins, who developed Hospital at Home, Presbyterian spent many months designing and building its own Hospital at Home program for implementation in 2008.

Hospital at Home: At a Glance • Provides hospital-level care for qualified patients in their homes. • A physician visits daily, nurses once or twice daily. • Ancillary services such as occupational therapy and physical therapy, as well as some tests such as EKGs and lab work, can be delivered in the home. • Once stabilized, patients are “discharged” and can receive more traditional home care services.

The health system has received national attention because of the program’s success, and has served as a learning laboratory for dozens of other health systems.

How the Program works: Hospital Care, Home-Delivered Patients come to the Hospital at Home program through three routes: They arrive at one of the emergency departments in any of Presbyterian’s three Albuquerque-area hospitals; they are referred from the community by a Presbyterian physician, their House Calls physician, urgent care center or the system’s home health agency; or they are transferred directly into the program from the hospital. To be eligible, patients must have a diagnosis on an approved list of conditions that can be effectively managed through a Hospital at Home program, and must be judged to be otherwise stable if treated and not at significant risk for rapid deterioration. They must be sick enough to meet an inpatient level of care, but not intensive care; live within 25 miles of one of Presbyterian’s Albuquerquearea hospitals; and be covered by Presbyterian Health Plan. When admitted to the program, they are seen by a nurse immediately. A physician or nurse practitioner visits every day, and registered nurses also come daily, often twice a day. Patients can also receive rehabilitation services, speech and occupational therapy, nutrition counseling and necessary medical equipment at home. The care team can also perform X-rays, EKGs and lab work in the patient’s home.

Dr. Melanie Van Amsterdam, Presbyterian’s lead physician for Hospital at Home, cares for Peggy in her apartment. When patients stabilize, they are discharged to a more traditional home care service, and often continue to received provider services from their Hospital at Home physician through House Calls. Depending on the patient’s condition, home health continues to assure recovery, complementing nursing services and rehabilitation therapy as needed. When patients regain enough strength to manage a clinic visit, care reverts to their primary care physician and Medical Home team, just as it would if they had been hospitalized. Hospital at Home patients with advanced illness are transitioned to a new program called Complete Care that is designed to ensure long-term home-based care, early identification of changes in condition and early interventions to prevent future emergency room visits and hospitalizations.

Results: Better Outcomes, Shorter Stays, Lower Costs Data from the program’s patients compared to hospital inpatients showed: • Shorter average length of stay: 3.3 days vs. 4.5 days. • Fewer readmissions: 3.2 percent average readmission rate vs. 9 percent nationally. • Lower mortality rates: less than 1 percent vs. 1.5 percent for hospitalized Medicare patients. • A fall rate of zero since the program began. • 96.8 percent patient HCAHPS satisfaction score (99th percentile rank).

Patient Story: Before and After Peggy had a history of congestive heart failure and COPD. After collapsing, she was admitted to Presbyterian Healthcare Services' Hospital at Home, receiving the same level of care at home she would have in a traditional hospital. She received at least twice daily visits from the nurse and a daily visit from her physician. “Whoever would have thought to have all of this wherever I might live?” Peggy said, adding that her doctor is “a real friend.”

In addition, Presbyterian points to gains such as avoidance of hospital-acquired infections and reductions in delirium, adverse drug events and other unintended consequences of inpatient hospitalizations. Post-acute services, particularly skilled nursing facility use, is dramatically reduced as patients are at home and maintaining their independence through the course of care. Since patients receive care in the comfort of their own home, they continue to engage in self-care activities around the home, mitigating the functional decline seen during a hospital stay and aiding in improved outcomes.

ACHP Case Study: Presbyterian Healthcare Services' Hospital at Home Program

Case Study

Fallon Health NaviCare and Summit ElderCare Programs Fallon Health offers an array of plans and programs for seniors, including two comprehensive programs designed to help seniors age in place: NaviCare, a Senior Care Options/Medicare Advantage Special Needs Plan, and Summit ElderCare, a Program of All-Inclusive Care for the Elderly (PACE).5 Fallon Health is the only health plan in Massachusetts and one of only a few in the U.S. that sponsors its own PACE. Background: An Early Start in Alternative Models of Care Fallon Health’s Summit ElderCare PACE program started in 1995 and now has five PACE centers and teams across central and western Massachusetts. The program provided care to 1,151 participants in 2014, making it the seventh-largest PACE program nationally. Summit ElderCare offers comprehensive care and coverage to area residents who are 55 years or older and meet Medicaid eligibility for nursing home care. The PACE model abides by the belief that seniors with chronic conditions should be served in a community setting. NaviCare was introduced as an additional Fallon Health solution for independent living in 2010. NaviCare currently has about 4,400 enrollees across Massachusetts, 95 percent of whom are dual-eligible. About 65 percent of NaviCare’s enrollees are nursinghome eligible. Through NaviCare, enrollees who are 65 or older receive all Medicare and MassHealth Standard (Medicaid) benefits, services and items. They also receive such community-based home and personal care services as adult day health, home-delivered meals or help with bathing and dressing needs.

How the programs work: Comprehensive Team Support Fallon Health leaders say that one of the keys to

NaviCare and Summit ElderCare: At a Glance • NaviCare offers a Special Needs Plan for dual-eligible individuals and a Senior Care Options plan for Medicaid recipients over age 65. In each case, members receive team care including home visits. • Summit ElderCare is a PACE plan offered to nursing-home qualified people 55 and older. They need not be Fallon Health members. • Fallon Health owns Summit ElderCare, so the health plan provides, coordinates and insures care. • Summit ElderCare includes five PACE adult day health centers, with a sixth currently under construction. • Both NaviCare and Summit ElderCare are designed to keep members at home as long as possible.

better outcomes for both programs is effectively addressing psychosocial and economic determinants of health, including the individual’s safety at home, transportation, socialization and other daily requirements.

5 PACE (Program of All-Inclusive Care for the Elderly) is a program that meets health care needs in the community instead of in a nursing home. Care is provided in the home, the community and at the PACE center, where seniors can gather during the day to be with others and receive all of their care needs in one location, including physical therapy, meals, social work, nutritional counseling, administration of prescription drugs and medical care provided by a PACE physician.

Participants in Summit ElderCare receive the full spectrum of care primarily at PACE centers, at home and in inpatient settings when needed — which supports retention of independence at home. Care is coordinated by an interdisciplinary team of health care professionals with geriatric expertise. Transportation is available to and from the PACE centers. Most participants spend several days a week at a center, which provides opportunities for socialization, recreation, rehabilitation therapy, medical and nursing care, and meals. In-home support includes help with bathing, dressing and meal preparation; medication management; and light housekeeping. For NaviCare enrollees, care is overseen and coordinated by a primary care team comprising their primary care physician, nurse case manager, behavioral health clinician and geriatric support services coordinator (for those who live at home) or facility liaison (for those in assisted living or long-term care facilities). Perhaps most important is the “navigator,” a key player who oversees and coordinates all aspects of the enrollee’s services. This navigator is a single point of contact for both the patient and the provider. Upon joining the plan, NaviCare enrollees receive a home visit by the primary care team comprising the nurse case manager, geriatric social worker and

navigator, as well as a behavioral health clinician, if appropriate, who perform a complete cognitive, environmental and physical assessment. The results are reviewed with the enrollee’s primary care physician and an individualized care plan is drafted to share with the individual and family, if appropriate. The care team and the navigator are responsible for executing the care plan. They regularly contact enrollees, and the navigator also organizes and coordinates benefits and services, advocates for appropriate care, helps schedule medical appointments and arranges for transportation if needed. The primary care team follows the patients through transitions of care.

Results: Utilization Down, Satisfaction Up NaviCare data show enrollee satisfaction rates at 98 percent for four years running. The plan has made the following observations of positive results as compared to Medicare Fee for Service beneficiaries6: • Acute admissions per 1000 are lower by 13 percent. • Skilled Nursing Facility (SNF) admits per 1000 are lower by 13.4 percent. • SNF days per 1000 are lower by 28.2 percent.

Choosing NaviCare or Summit Eldercare Fallon Health outreach staff for NaviCare and Summit ElderCare helps prospective individuals to choose the most appropriate plan. The choice may be based on an existing relationship with a primary care physician, sometimes on geography, or on special needs. Both programs offer comprehensive, coordinated care and in-home support, with the key difference being that the Summit ElderCare interdisciplinary care team provides all the clinical care for participants.

• PM/PM cost savings are estimated at $128.20. Summit ElderCare PACE participants are also highly satisfied, with 100 percent willing to recommend the program to friends or family. One hundred percent of PACE participants have advance directives and the plan has advance care planning discussions documented for 85 percent of its participants. A state-sponsored study7 of PACE plans found they save money and delay nursing home placement by at least 20 months for PACE participants, compared to non-PACE participants. Median length of stay in the program is 27 months, but has been as long as 10 years. All participants are nursing facility certifiable yet the 2014 30-day readmission rate is only 15.7 percent compared to a SNF return to the hospital rate of 23.5 percent and general Medicare population readmission rate of 18.4 percent.8, 9

Compared to the Centers for Medicare and Medicaid Services, 5 percent Worcester County sample dual eligible 65+ weighted for Fallon Health mix of institutional/non-institutional and adjusted for utilization and intensity. 7 JEN Associates, Inc. Massachusetts PACE Evaluation Nursing Home Residency: Summary Report (July 24, 2014). Retrieved May 8, 2015, from National Pace Association website, http://www.npaonline.org/website/download.asp?id=6253&title=Massachusetts_PACE_Evaluation_Summary_Report_7.31.14. 8 Toles M, et al. Restarting the cycle: incidence and predictions of first acute care use after nursing home discharge. J Am GeriatrSoc 2014;62:79-85 9 Mor V, et al. The revolving door of rehospitalization from skilled nursing facilities. Heath Aff (Millwood) 2010; 29:57-64 6

ACHP Case Study: Fallon Health NaviCare and Summit ElderCare Programs