Hopkins ElderPlus

Johns Hopkins Health System
Baltimore, MD
912 Beds

The Problem
Hopkins ElderPlus is the Programs of All-inclusive Care for the Elderly (PACE) program of Johns Hopkins Health System, providing all primary, acute and long term services and supports under integrated Medicare and Medicaid financing to approximately 150 beneficiaries.

The Solution
To ensure that Hopkins accepts the appropriate patients into the program, PACE participants must fit the following eligibility requirements: 55 years old, certified by the state as needing nursing home care, ability to live safely in the community at time of enrollment and reside in a PACE service area. Each beneficiary goes through an intensive medical, social and behavioral assessment to gain an understanding of which services will be essential for each patient. Although a fluid adjustment on service changes, the multidisciplinary staff (including everyone from physicians to housekeeping aides and social workers) holds a quarterly intake and assessment meeting for each participant, offering insights into how the participant is doing, identifying any problems, flagging potential future issues, and discussing how to improve the participant's care moving forward.

As with all PACE programs, Hopkins receives a separate Medicare and Medicaid capitated benefit on a per member per month rate, and all necessary services are coordinated within that amount.

The Result
Evaluations of the PACE model have found them to be successful in several outcomes including: health and functional status, quality of life, length of survival (4.2 years) and service satisfaction. In spite of increased beneficiary complexity, PACE sees readmission rates similar to those of the overall Medicare population. Virginia programs estimate that the cost to the state for PACE Medicare and Medicaid is, on average, $4,200 less per year compared to a person receiving Medicaid services at home or in a nursing facility.

This case study was originally featured in the HPOE guide: 'Caring for Vulnerable Populations,' published January, 2012.