Program of All-I nclusive Care for the Elderly Serving I ngham , Eaton & Clinton 1 and few adjacent Counties
Orientation I ncludes • What is Senior CommUnity Care of MI (SCCM) PACE • When to contact SCCM PACE • Grievances & Appeals • Participant Rights • Emergency Care • Fraud, Waste & Abuse 2
PACE Developm ent • PACE stands for Program of All-Inclusive Care for the Elderly. Main goal is to help older adults remain home when their care needs advance. • There are over 120 PACE programs in the U.S. serving over 40,000 participants across 31 states. • PACE programs are developed in an area of need via partnerships. SCCM PACE is a strong partnership of Volunteers of America National Service, Ingham County Medical Care Facility and United Methodist Retirement Communities. Eaton, Ingham & Clinton Counties. • Approximately 250 participants will be served at maturity (year 4). SCCM PACE started on April 1, 2015. 3
PACE Developm ent • PACE is essentially, through Medicaid, the person’s insurance. PACE covers and is the payer for all medical and supportive services that traditional insurance covers but ALSO provides medications (zero copays), home health aides, a day center and medical transportation. • PACE is funded through the Centers for Medicare and Medicaid Services (CMS) with a monthly capitated rate. • The PACE model of Care promotes that it is better for the well-being of older adults with advanced care needs and their families to be served within the community whenever possible. 4
PACE Services • PACE provides the full array of services in all health care settings but primarily in the home, wherever home is outside of a nursing facility. (PACE is considered a Home Based Long-Term Care Program) • PACE emphasizes wellness and prevention services to avoid hospitalizations and nursing facility stays. • Participant’s receive certain services at the PACE center: medical care/clinic, therapy services and recreation therapy/socialization opportunites. • PACE relies on a comprehensive provider network for 5 home care, specialty, acute care and long term care
PACE Services Services are coordinated through an interdisciplinary team that includes a physician, PACE center manager, home care coordinator, dietician, nurses, social workers, therapists, transportation staff and others. Services: Adult Day at PACE Center Rehabilitation Therapies Medical Transportation Respite Services Specialty Care Home Chore Assistance Nursing Care Personal Care Assistance Prescription & OTC coverage Hearing Care Medical equipment Dental & Vision Care Meal Support Podiatry Mental Health End of Life Hospital Sub Acute Rehabilitation Nursing Facility (if needed) Emergency Medical Services 6 Lab Work, X-Rays, Testing 24 Hour On-Call Nurse
PACE Eligibility Requirem ents PACE Participants must be: • Age 55 or older • Eligible for a nursing facility level of care – Help with transferring, ADL’S – Memory, Decision Making – Oxygen 24/7 • Reside in the PACE geographic service area • Able to live safely in the community with PACE services Financially: For the program to be at no cost, income needs to be under $2,250/month and assets under $2,000 (with exceptions) Private pay is an option. • Over 90% of PACE consumers are dually eligible for Medicare and Medicaid. 7
Three County Dem ographic Map 8
W hen to Contact PACE • When a participant has a change in his or her health status or you believe a change in services in needed • When you have concerns about a participant’s safety at home • When a participant voices a complaint about their care or services – a grievance • When you have questions about service orders or billing • When you identify other consumers who would benefit from PACE – make a Referral 9
Participant Grievance • A grievance is defined as any concern or complaint about any PACE service voiced by a SCCM participant • It is important that you communicate any complaints or concerns voiced by a SCCM participant to your designated SCCM representative (Quality Assurance) • SCCM is required to complete a grievance form and follow-up appropriately to address the concern or complaint • SCCM also analyzes grievances and track and trends all grievances as a part of the SCCM Quality and Performance Improvement program 10
Participants Rights • PACE participants are afforded participant rights through the CMS PACE regulations • PACE programs are required to educate PACE staff, contractors, and participants annually on the PACE participant rights • SCCM has participants rights visible in our Adult Day PACE Center • Contract Providers are given a copy of the participant rights as part of the Approved Provider Agreement. SCCM is providing a copy of the participant rights as part of this presentation 11
Participant Appeals • The SCCM Interdisciplinary team authorizes all services and care for participants enrolled in the SCCM PACE program • Any enrolled participant has the right to “appeal” the decision of the SCCM Interdisciplinary team • It is important to communicate to your SCCM representative any time you hear from a SCCM participant that they would like to appeal a decision made by the IDT team • SCCM is required to follow specific policies and procedures for all participant appeals. 12
Quality Assurance • SCCM has a formal QAPI program (Quality Assurance and Performance Improvement) • The program is re-evaluated yearly and a specific work plan is developed every year • The QAPI program is interdisciplinary focused and data – driven to maximize quality improvement opportunities • As an approved SCCM contract provider, SCCM may require your organization to submit certain data and reports so that we can evaluate that services are being provided appropriately and efficiently for SCCM participants • SCCM also conducts routine oversight of all contract providers as well as episodically when necessary 13
Fraud, Waste, and Abuse • SCCM provides all prescription medications for participants through the Medicare Part D program • As part of our participation in the Part D program, SCCM follows all CMS Part D guidelines • SCCM has an internal Part D Compliance Committee that monitors and ensures that we are in compliance with Part D requirements • As a part of the compliance activities, SCCM monitors the program for FWA (Fraud, Waste, and Abuse) • Examples of FWA may include the following; – improper dispensing of meds – Improper billing for medications – Wasting of medication – Diversion of meds to family members or selling meds in the community As an approved SCCM contractor, you have the responsibility to communicate to your SCCM representative any known instances or 14 occurrences of FWA
Em ergency Care • All Care and Services with the exception of emergency services need to be authorized by the SCCM Interdisciplinary team. • SCCM will work with all Contract Providers to make sure that they understand the proper procedures to communicate with SCCM when confronted with the need of emergency services • SCCM has a 24/7 on call line where providers and participants can call to report any change of condition or emergency • Since SCCM follows participant care through all care continuum's, including the Emergency Room and Hospital, it is important that SCCM is contacted anytime a participant access emergency services, including going to the Emergency Room 15
Sum m ary - Com m unication • It is important that as an approved provider of SCCM PACE the following is always communicated to your SCCM PACE representative • Any changes of conditions • When you have a concern about a participants ability to live safely at home • Any grievance • Any appeals • Any Quality Assurance Issues • Any Emergency Services (SCCM always needs to be notified) • Any instances of Fraud, Waste, and Abuse in the Prescription Drug Program 16
For Questions and Other Com m unications – Contact: Care/Clinical Issues – 517-319-0720 Referrals – 517-319-0681 Business Office – 517-319-0694 Grievances – 517-319-0654 After Hours & General (517) 319-0700 Emergency Transport (Mercy Ambulance) 517-482-1245 or 911 17
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