PACE allows frail elderly to stay at home, yet under the watchful eyes of an interdisciplinary care team
Andrea Logan believes she has seen a viable option for healthcare for the elderly right in southeastern Michigan. It’s a program called PACE. “It offers truly coordinated care for the senior population,” says Logan, vice president of sales, TwinMed, LLC.
PACE – the Programs of All-Inclusive Care for the Elderly – provides comprehensive medical and social services to certain frail, community-dwelling elderly individuals, most of whom are dually eligible for Medicare and Medicaid benefits, according to the Centers for Medicare & Medicaid Services. For most participants, the comprehensive service package enables them to remain in the community rather than receive care in a nursing home. (Participants frequent the local PACE day center to see physicians, therapists and nutritionists, and simply to socialize.)
Currently, there are 121 PACE programs in 31 states serving 38,072 participants, according to the National PACE Association. The state of Michigan has 10.
PACE uses interdisciplinary care teams – including physicians, nurse practitioners, nurses, social workers, therapists, van drivers, and aides – to exchange information and solve problems as the conditions and needs of each participant change, according to organizers at On Lok, a San Francisco, Calif.-based nonprofit organization credited with starting (and continuing to operate) the first PACE program in the country in 1979. Providers deliver all medically necessary services participants need rather than only those reimbursable under Medicare and Medicaid fee-for-service plans.
“I’m enthusiastic about PACE because everything is coordinated, from doctors’ visits, to lab, to medical equipment, to disposable products,” she says. A team of professionals provides individualized care plans, rather than leaving that burden to the family. “It’s truly the only coordination of Medicare and Medicaid benefits. It’s cost-effective. But the best thing is, seniors get to be in their own homes, and who wouldn’t want that?
“I see this as a solution to the problem we’re going to be facing in the next 10 years, as Baby Boomers with limited funds face some big financial challenges.”
‘Think preventive’
Huron Valley PACE in Ypsilanti, Mich., is approved for 225 participants, and right now, provides services for 140, says Rick Bluhm, executive director of the program, which serves Washtenaw and parts of Monroe Oakland, Wayne and Livingston counties. The state of Michigan caps the organization’s enrollment each month. Huron Valley PACE will be at capacity in 14 to 16 months.
“We provide all Medicare and Medicaid covered services, including Part D drugs,” says Bluhm, who was director of the University of Michigan Health System’s geriatric division prior to helping launch Huron Valley PACE in March 2014. ”We were the sixth PACE program in Michigan; and the 100th in the United States when we opened,” he says.
United Methodist Retirement Communities Inc. in Chelsea, Mich. – a provider of residential and long-term care facilities and other health and human services for seniors in southeastern Michigan – has an 80 percent interest in Huron Valley PACE in Ypsilanti, as well as an 80 percent interest in Thome PACE in Jackson, Mich., and a 20 percent interest in Senior CommUnity Care of Michigan in Lansing, explains John Thorhauer, president and CEO of United Methodist Retirement Communities.
“UMRC has 110 years of experience helping older adults not just live, but to live well,” he says. “PACE allows us to promote independence, improve quality of life and provide necessary services where they are needed, when they are needed, regardless of income.”
Huron Valley PACE is a managed care company that has a contract with CMS, he explains. “The thing that’s unique about PACE is, there’s no middleman between the insurance piece and the provider.” Huron Valley PACE operates as a staff model, meaning its doctors and clinical staff are often salaried employees.
“In the fee-for-service world, doctors see patients when those patients are sick or there is some medical necessity,” he says. “Our physicians are on staff to care only for our participants. They provide preventive care, working to reduce hospitalizations, ER visits, nursing home stays. There are no mixed incentives in our model.
“We need to be proactive and ‘think preventive’ in order to help our participants avoid exacerbation of the chronic illnesses they have, along with [ramifications] of aging. Our goal is to increase quality of life and independence, and help them live safely in the community until the end of their lives.”
PACE participants can see physicians and other team members without an appointment. “We are responsible for them 24/7,” says Bluhm. The day center offers physical therapy and occupational therapy; a recreational common area where people congregate for meals, activities, socializing; personal care rooms, where participants who need help with bathing can receive it; and a laundry facility, so participants always have clean clothes. The organization provides transportation to and from the day center for those who need it.
“We don’t have specialists onsite, but we make referrals, schedule appointments and provide transportation to other providers when necessary,” says Bluhm.
By virtue of its participation in Medicaid, Huron Valley provides home meals, some care-related services in the home, and even modest modifications to the home (e.g., ramps or even bedbug remediation). The day center has a pharmacist, and Huron Valley PACE delivers medications directly to participants’ homes.
Coordinated care
“The No. 1 thing about PACE is the coordinated care,” says Thorhauer. “We’ve been in the healthcare industry 110 years, and we see firsthand what happens when people have to use different parts of the health system. It’s very uncoordinated. There are a lot of handoffs, and everybody assumes everybody else has all the information on the patient. But we truly do have access to that information, and we follow through.”
The PACE staffing model allows the organization to follow participants wherever they are in the healthcare system, he continues. “If a participant goes into the hospital, a physician who works with our contracted hospital communicates directly with that patient’s PACE physician. We provide a lot of services, and for those we don’t provide, we provide a high level of coordination.”
Hospitals can find it challenging to deal with frail older adults who lack a support network, he says. For example, if the hospitalist arranges a post-discharge visit, there’s no assurance the patient will make it, or that they will take their medication as instructed. “We serve as family support for those who lack it. We accompany [participants] to the follow-up visit; we get the results from that visit and share it with the interdisciplinary team; we monitor the participant’s medications. We spend more money upfront on preventive measures instead of letting things fall where they may.”
Healthcare professionals who work within PACE either come to the program with a well-developed sense of teamwork and collaboration, or are open to learning about it, says Thorhauer.
“The physician has no more authority than the bus driver or the home worker, who often know as much about what’s going on with the client,” he says. “The bus driver might observe something as the person is getting onto the bus; or a certified nursing assistant may observe something at home that is valuable to that person’s care.”
Team members meet daily to review changes in their participants’ circumstances and strategize on solutions. It differs from the traditional approach, in which caregivers may exchange notes or medical records, but never speak to each other, says Thorhauer. “In PACE, the nurse is speaking with the doctor, the bus driver, the dietician, the social worker, the pharmacist. They interact, so they can come up with the best solutions.”
Where is PACE headed?
“We’ve been here almost three years, and we are becoming more well known in the community,” says Bluhm. “It has been rewarding to see how quickly PACE has been accepted in the community, and the strong number of referrals we receive each month.” Many of those referrals come from home health agencies. Hospitals have proven to be strong referral sources too, as well as primary care doctors, specialists, meals programs, churches and others.
“Will PACE serve millions of people in Michigan?” asks Thorhauer. “No. But it could serve hundreds of thousands of people in a given state.” For that to occur, organizers would have to open up more day centers around the state, and that presents its own set of challenges.
Starting a program calls for a significant capital investment, and payback can’t be expected for two to three years, he says. There’s the cost of securing a building for the day center, either through lease or purchase, plus improvements. Then the organization has to hire a staff and train them.
Even so, because of the benefits of the program, Huron Valley PACE is exploring ways to provide services to a broader population than it currently does, says Bluhm. Some examples:
- Participants who are eligible for Medicare but not Medicaid. “We could create some pricing tiers for what Medicaid would have covered, so they would only pay for what they use or need,” he says.
- Participants who are not quite nursing-home-eligible.
- Participants who are eligible for Medicare but who earn just enough money to make them ineligible for Medicaid.
“Given the continued focus on managed care and the Triple Aim of healthcare – better health, better care, and lower cost – we believe PACE is well positioned to continue to serve very frail older adults,” says Thorhauer. “Data suggests that PACE offers very high participant satisfaction for a lower cost and keeps participants at home and out of institutions. In fact, we are able to keep approximately 98 percent of our participants at home.
“Regardless of whether the Affordable Care Act is repealed, modified or replaced, PACE is a viable, responsible model for delivering high quality care in a cost-effective manner.”
Individuals can join PACE if they meet certain conditions:
- Medicare- and Medicaid-eligible
- Age 55 or older
- Live in the service area of a PACE organization
- Eligible for nursing home care
- Able to live safely in the community
PACE services include:
- Adult day care
- Preventative services and education
- Recreational therapy
- Meals
- Optometry and dentistry
- Nutritional counseling
- Social services
- Laboratory/X-ray services
- Social work counseling
- Medical transportation
- Primary care (including doctor and nursing services)
- Medical specialty services
- Medications
- Hospital care and long-term care
- Prescription drugs
- Emergency services
- Home health and personal care
- Physical, occupational and speech therapy
- Caregiver respite
- Medical equipment
PACE also includes all other services that are available in its service area and determined necessary by the participant’s team of healthcare professionals to improve and maintain overall health.
PACE expansion to be tested
The Centers for Medicare & Medicaid Services released a Request for Information (RFI) seeking public input on potential adaptations of the Programs of All-Inclusive Care for the Elderly (PACE) for new populations, including individuals with physical disabilities, under the authority provided by the PACE Innovation Act.
The PACE Innovation Act of 2015 (PIA) provides authority to test application of PACE-like models for additional populations, including populations under the age of 55 and those who do not qualify for a nursing home level of care.
The RFI includes two parts:
- In the first part, CMS seeks comment on potential elements of a five-year PACE-like model test for individuals dually eligible for Medicare and Medicaid, age 21 and older, with disabilities that impair their mobility and who are assessed as requiring a nursing home level of care, among other eligibility criteria. CMS has provisionally named this model “Person Centered Community Care” or P3C.
- In the second part of the RFI, CMS seeks information on additional specific populations whose health outcomes could benefit from enrollment in PACE-like models, and how the PACE model of care could be adapted to better serve the needs of these populations and the currently eligible population.
The RFI is available at: https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/PACEInnovationAct.html