committed to serving California’s diverse communities

NAMI 2009 National ConventionThe On Lok Model: 

Comprehensive Community Support for Older Adults of Diverse Cultures

Grace Li, MHADirector of Program Operations

Ellen Dekker, MFTMental Health Clinician

San Francisco, CA July 9, 2009

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Outline

1. Overview of On Lok Lifeways• History of On Lok • Overview of PACE Model• Care Planning and How it Work • Legislative and Regulatory Framework

2. The Mental Health Program• Overview of the MHP• The Mental Health Team: Roles and Responsibilities• Case Illustrations

3. Discussion• Q&A

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What Is On Lok?

• Began in 1973 as one of the first adult day health care programs in the country

• National prototype for the Program of All-inclusive Care for the Elderly (PACE) model of care

• Family of non-profit corporations with mission of providing quality and affordable care services to seniors

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On Lok’s History & Background

1972 On Lok founded as a non-profit organization• Premise was that providing services to maintain seniors in their own homes was both a better and lower cost model of care

1975 On Lok’s first major regulatory/reimbursement victory in pioneering new models of care for the elderly• As one of five demonstration projects in CA, On Lok successfully advocated for Adult Day Health Care to become a reimbursable service under Medi-Cal

1979 Health Care Financing Administration (HCFA) grants waiver to offer a comprehensive program for care for the elderly• A true revolution in the method and quality of health care for the elderly

1983 On Lok gets approval for Medicare and Medi-Cal waivers for capitated reimbursement

1986 On Lok obtains permanent waiver status and attracts major foundations to fund replication of the On Lok Model in different locations as “PACE” (Program of All-inclusive Care for the Elderly)

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On Lok’s History & Background

1996

1997

On Lok expands operation to serve all of San Francisco

PACE became a permanent provider for Medicare and an option for State Medicaid agencies under the Balanced Budget Act in 1997

1999

2002

2003

2006

2008

On Lok receives a Knox-Keene HMO license in order to facilitate its efforts to expand

On Lok expands to Fremont with community physician waiver

On Lok becomes a permanent PACE provider under Medicare and Medi-Cal

On Lok adds another center to serve southern part of San Francisco

On Lok expands to San Jose

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History of the PACE Model

19861986 19901990 19971997 (Nov)(Nov) 1999 1999

First Demonstration

Sites Operational

Legislation Authorizing

PACE Demonstration

Congress AuthorizesPermanent Provider

Status

Balanced Budget Act of 1997, H.R. 2015

Washington, D.C.

Publication of Interim

Final PACE Regulation

First Program Achieves

Permanent PACE

Provider Status

(Nov)(Nov) 2001 2001

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Program Description: PACE Model

• PACE is a provider-based Medicare and Medicaid managed care program

• PACE serves individuals at least 55 years old and who are certified by the State to meet nursing home eligibility criteria

• PACE coordinates and provides all needed preventive, primary, acute and long term care services so that individuals can continue to live in the community

• PACE uses interdisciplinary teams to assess need, provide and manage care

• PACE programs receive capitation payments from Medicare and Medicaid and assume full financial risk for the care of their participants

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The PACE Model: Who Does It Serve?

Eligibility Criteria:• 55 years of age or older• Living in a PACE service area• Certified as needing nursing home care• Able to live safely in the community at the

time of enrollment

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Revenues: Integrated Financing Sources

MEDICARERisk Factor plus Frailty AdjustorX county rate1

MEDICAID and/or PRIVATE PAY

Rate at 90% 2 of comparable cost of

long-term care population

MONTHLY CAPITATION

1 Risk Factor (based on individual demographic and medical diagnoses) combined with organizational Frailty Adjustor (based on ADL) is applied to county fee-for-service rates; new methodology for Frailty Adjustor being phased in over 2008-2012

2 California law requires DHCS to set PACE capitation rates at no less than 90% of the fee-for-service equivalent cost for a comparable long-term care population (California Welfare and Institutions Code §14592 (c))

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Provider Services: Integrated, Team Managed Care

Interdisciplinary Teams

Program ManagerHome Care Pharmacy

Nutrition

OT/PT

Primary Care/ Nursing

Transportation

Personal Care

Recreation Activities

Social Work

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PACE Comprehensive Services

Interdisciplinary

Coordination

On Lok Participant

A cute H ospital

Care

In-H ome Day H ealth Care Care

Primary Care

Laboratory X-Ray

A mbulance Service

Services

M edical Specialty Services

Restorative/ Supportive

Services

Skilled N ursing

Facility Care

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On Lok’s PACE Participant Profile

• Profile of typical participant

• Female; average age of 84• 13 medical conditions• Dependent in 2.7 ADL’s (bathing, dressing, etc.)• Has some degree of cognitive impairment (59%)• Dually-eligible for Medicare & Medi-Cal (94%)• Enrolled in program last 3-4 years of life

• Serves culturally and linguistically diverse population 64% Asian/Pacific Islander, 18% Caucasian, 12% Hispanic, 6% African American

• Currently serving over 1030 participants throughout the greater Bay area

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Participants by Living Situation -May 2009

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Care Management

• Interdisciplinary Team (IDT) care planning• Daily IDT meetings to review and discuss care needs and changes

in status• Treatments• Evaluations

• Frequent monitoring• Average contact with each participant is 2.2 days/week• Quarterly assessments

• Collaborative care planning with participants and family members

• Insures and improves quality of care• Maintains participant autonomy

• ICCIS (electronic medical record)• Enables communication of treatment plan, changing conditions and

tracking service utilization

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Participant Evaluations

• Each On Lok Lifeways participant receives a comprehensive team assessment upon enrollment and semi-annually.

• Participants who have experienced a significant change during the preceding quarter (e.g., stroke, hospitalization, etc.) or whose chronic conditions are unstable will receive a complete, in-person assessment each quarter.

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Participant Treatment Planning

• Interdisciplinary Teams (IDT) are responsible for assessing needs, developing treatment plans, and delivering and managing services for On Lok Lifeways participants.

• Treatment plans are modified as needed and reflect the Program’s flexibility in meeting the on-going and ever-changing needs of our participant population.

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Participant Treatment Planning

• The IDT considers a wide range of factors when treatment planning and discusses coordination issues such as:

• Number of days per week of center attendance• (recreation/socialization, maintenance therapies, primary care and nursing services, meals, etc.)

• Type and hours of in-home services• Need for alternative housing or long-term nursing home placement

• Adding, reducing or stopping any given services to maximize independence

• End of life care planning

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Participant Treatment Planning

• Psychosocial intervention and individual counseling/support may include:

• Family counseling• Case management• Life review• Assistance with housing• Financial management• Pre-need funeral trust account• Coordination with primary care provider/psychiatrist for psychiatric

intervention• Bereavement counseling• Group/individual counseling

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Medical Management

• The goal is to maximize medical management in the outpatient setting and integrate social and functional support needs with IDT

• Primary care team on-site: MD, NP, RN• Full-service clinic for urgent care and management of chronic

conditions IV and Respiratory therapy Wound care management Frequent visits for management of chronic disease such as CHF, diabetes,

chronic lung disease

• Effective management of end-of-life care Require discussion of advance healthcare directives within 6 months of

enrollment Goal is to provide care of terminal illness in home instead of acute hospital

• Home health services

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On Lok’s Enhanced Program Services

• Mental/Behavioral Health (MBH) Program • Hired an internal mental/behavioral health team (Psychologist, LCSW,

MFT) and contract with other providers (Psychologists, Psychiatrists)• Developed practice guidelines, staff training materials, referral protocol• 29 percent of participant population utilizing services (2008)

• Dementia Training• General overview• How to provide personal care• How to manage wander risk behavior• How to manage sexual behavior

• Chaplaincy Program• Offer on-site chaplain to act as spiritual resource/support to

participants, caregivers, families, staff

committed to serving California’s diverse communities

Mental Health Program for Culturally Diverse Elders

Ellen Dekker, MFTMental Health Clinician

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•2 Licensed Marriage and Family Therapists (MFT; 1.5 FTE)

•1 Licensed Psychologist (0.6 FTE) •1 Licensed Clinical Social Worker (LCSW; 0.8 FTE)

•3 Psychiatrists (0.25 FTE)

Mental and Behavioral Health (MBH) Team

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PSYCHIATRIST

•Medication management as requested by PCP for complex psychiatric diagnoses

PSYCHOLOGIST

•Coordination of services•Assessment of mental and behavioral health needs for new enrollees

•Neuropsychological assessment for participants with cognitive impairments and / or behavioral problems

MBH Team Responsibilities

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LCSW or MFT

•Routine reassessment for participants with mental health diagnosis

•Crisis intervention and management (72 hour involuntary psychiatric hospitalization (CA 5150))

• Individual therapy for participants, and support services for their families or caregivers

•Psycho-education & consultation about mental illness and dementia, and trainings for staff and caregivers

MBH Team Responsibilities

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Psy

chia

tris

ts

Interdisciplinary Team (IDT)

PCP SW

MBH Core Team

Psy

chia

tris

ts

Interdisciplinary Team (IDT)

PCP SW

MBH Core Team

MBH Team

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• Direct Services • Assessment/ Evaluation• Treatment

• Indirect Services• Consultation• Staff Training

MBH Services

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Most common reasons for referral- Depression

- Anxiety

- PTSD

- Mania/ Hypomania

- Psychosis

- Adjustment issues

MBH Services

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MBH - Direct Services

CASE OF MS. G.

64 year old bilingual Hispanic female referred to Mental Health Clinician (MHC)

for recurrent MDD

•Depressive episode resolved within 6 months; hypomanic symptoms observed 6 months later

•PACE setting allowed MHC to note hypomanic episode and note misdiagnosis

•Ms. G. successfully treated for Bipolar II Disorder

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MBH - Direct & Indirect Services

CASE OF MS. B.

79 year old Spanish speaking female, successfully treated for PTSD, was at risk for

relapse because of her recent transfer to a SNF.

Mental Health Clinician was able to provide both direct and indirect services to help prevent a recurrence of PTSD.

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MBH Direct and Indirect Services

CASE OF MR. Y.

78 Year old monolingual Chinese American male with history of Bipolar Disorder was involuntarily

hospitalized for self-injurious behavior by bilingual Chinese MHC.

CHALLENGE:

How to safely maintain Mr. Y in his home environment considering high family burn-out and staff anxiety

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MBH Direct and Indirect Services

MR. Y. MHC PROVIDED:

• Direct Service: supportive counseling to Mr. Y. and his family in the hospital

• Indirect Service: provided education to IDT to decrease anxiety and increase knowledge

CONSEQUENCE:• Mr. Y. discharged and treated with psychotropic medication and regular psychotherapy

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MBH Direct and Indirect Services

CASE OF MR. & MRS. V.

Bilingual Spanish couple in their 90’s, married 50 years, require different levels of care. Mr. V. suffers from moderate-severe Dementia and Ms. V. suffers from MDD. Both are at risk in their current B & C setting.

The IDT disagrees as to whether it is in the

best interest of the couple to place them

in separate settings (SNF and B & C).

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MBH Direct and Indirect Services

MR. & MRS. V.

MHC engaged in multiple roles to help resolve the IDT’s conflict: consultant & facilitator for staff and advocate & therapist for Mrs. V.

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Staff Training

Behavior Management Program

• Why the program is needed

• What the curriculum is comprised of

• Who is trained

• Ongoing consultation

MBH Indirect Services

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Staff Training: In-Services In-services for different disciplines

and for different centers

* Discipline specific ( e.g.: SW training: Suicide Assessment, Cognitive

Deficits

* Center specific

( e.g.: Frontal Lobe Dementia, Personality Disorders)

MBH Indirect Services

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Impact of the On-site

MBH Program

On Lok Lifeways

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Year Prts ServedPsychiatric

Admissions

Percent of Prts receiving MH

Services

2004 1082 11 10.1

2005 1107 2 14.7

2006 1214 3 23.8

2007 1227 3 24.4

2008 1188 2 29.3

Mental Health Utilization

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129.4

27.1

41.2

23.6

8.41

0

20

40

60

80

100

120

140

2004 2005 2006 2007 2008

Ps

yc

hia

tric

In

pa

tie

nt

Da

ys

/10

00

prt

s

Psychiatric Inpatient Days

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• Increases quality of care by providing timely mental health services to the participants;

• Provides mental health services to a higher percentage of enrollees;

• Reduces the number of institutional psychiatric admissions and overall number of inpatient psychiatric days;

• Increases Interdisciplinary Teams (IDTs) awareness of mental and behavioral issues; and

• Decreases staff anxiety by regular collaboration of the IDT and MBH teams on service / treatment development.

On-site MBH program at On Lok

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On Lok

DPH Regulation for Licensure

9 - ADHC

1- Home Health*

DPH Regulation for Licensure

2 - Dietary SF Health Dept Regulation

9 - Clinics DPH Regulation for Licensure

CMS PACE Regulation Knox-Keene HMO RegulationMedi-Cal Regulation/

DHCS Contract

Program Description: Regulatory Framework

CMS = Centers for Medicare and Medicaid ServicesDHCS = California Department of Health Care ServicesDPH = California Department of Public Health•Licensed, but not Medicare certified as a Home Health Agency.•PACE Regulations found at: http://www.cms.hhs.gov/PACE/03_Regulation&Background.asp#TopOfPage

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On Lok’s Ten PACE Centers

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Jade Center – Lion Dance

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Montgomery Center – Intergenerational Program

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Fremont Center – Recreation with the Sisters

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30th Street Center - Mural

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PACE Programs Around the Nation

70 PACE providers, 33 States

committed to serving California’s diverse communities

Thank you!

Q & A and Wrap UpAll