Program Of All-Inclusive Care For The Elderly Model Research Articles

Program of All-Inclusive Care for the Elderly (PACE) Organizations Flip the Script in Response to the COVID-19 Pandemic

ObjectivesProgram of All-Inclusive Care (PACE) organizations faced unique challenges during the COVID-19 pandemic, particularly given PACE participants are frail older adults who often live with multiple disabilities and chronic conditions. This study describes how PACE programs leveraged their unique program flexibilities and adapted services to manage this crisis. DesignMixed methods. Setting and ParticipantsThis study leveraged 2 national surveys of PACE directors (with response rates of 71.2% and 67.8%) and 6 qualitative interviews. MethodsDescriptive and univariate analyses of survey response data and thematic analyses of qualitative data from interviews and open-ended survey questions were conducted. ResultsResults indicated that PACE organizations responded rapidly to the COVID-19 pandemic, implementing a range of adaptations that shifted the PACE model from primarily center-based to a home-based model of care. Most PACE organizations reported increasing the in-home services they provided, often accomplishing this through the redeployment of center-based staff. PACE organizations likewise leveraged telehealth and remote monitoring to increase support to beneficiaries in their home, implemented various COVID-19 vaccine and infection prevention efforts, increased food and nutrition services provided in the home, and took steps to address social isolation and boredom, among other initiatives. Most PACE organizations indicated they plan to continue delivering more services in the home, consistent with participant preferences. Conclusions and ImplicationsThe findings from this study indicate that PACE organizations continued to keep participants at the forefront as they transitioned to a home-based model during the COVID-19 pandemic. Key characteristics of PACE, including its strong emphasis on person-centered team-based care, its fully integrated service model, and its flexible capitated payment structure, contributed to the resilience of the program. These findings highlight PACE organizations' ability to empower nursing home–eligible older adults to remain living in their preferred residential setting and have implications for how best to serve this population.

PACE AND FFS MEDICARE OUTCOMES BEFORE AND DURING COVID-19: A PROPENSITY SCORE MATCHED ANALYSIS

Abstract We compared outcomes of Program of All-Inclusive Care for the Elderly (PACE) participants and fee-for-service (FFS) Medicare, dually eligible individuals using a retrospective cohort study with propensity score matching on demographic, socioeconomic, and participant-specific acuity level variables. PACE participants in 132 PACE centers nationwide who were dually eligible, enrolled during the study period, and did not have end-stage renal disease were included. Over 80% of eligible PACE participants were matched with FFS beneficiaries during each period, bringing many covariates closer between groups. We assessed differences during each period using Wilcoxon signed rank test and over time using differences-in-differences analyses. PACE participants spent significantly more time in the community and less time in nursing homes and hospitals (all p< 0.01). PACE participants had fewer COVID-19 diagnoses and hospitalizations per member per month (all p< 0.01). Due to the blinding of data, we could not determine definitively which performed better in limiting severe pressure ulcers. However, the results indicate PACE performed better when the mean assumption for blinded data is used. For all-cause mortality, PACE participants continued to perform better than FFS both before and during the pandemic (all p< 0.01), but the rates were closer during the pandemic periods. The flexibility in the PACE model and its person-centered care delivery approach may have contributed to the positive outcomes compared to FFS before and during the pandemic. We should consider how best to leverage the PACE model of care to support older adults to remain in their homes and avoid institutional settings.

PROGRAM OF ALL INCLUSIVE CARE FOR THE ELDERLY ORGANIZATIONS FLIP THE SCRIPT IN RESPONSE TO COVID-19

Abstract The Program of All-Inclusive Care for the Elderly (PACE) is a unique care delivery model providing comprehensive, community-based, person-centered services to older adults. The COVID-19 pandemic posed unprecedented challenges for PACE organizations to continue providing services while mitigating infection risk, and they were agile and creative in their response. This study leveraged two national surveys and six interviews with PACE directors to examine how PACE organizations met these challenges. The response rate was 71.2% for the first survey and 67.8% for the second. Results revealed a rapid transition of the PACE model from primarily center-based to home-based care. To aid this transition, PACE organizations redeployed staff, repurposed day centers, and leveraged technology, among other strategies. Most PACE organizations plan to continue delivering more services in the home, consistent with participant preferences. The findings from this study indicate that PACE organizations continued to keep participants at the forefront as they transitioned to a home-based model. These findings highlight PACE organizations’ ability to empower nursing-home-eligible older adults to remain living in their preferred residential setting and could inform lasting changes in PACE service delivery.

Impact of COVID-19 on Structure and Function of Program of All-Inclusive Care for the Elderly (PACE) Sites in North Carolina.

ObjectivesThe novel coronavirus disease 2019 (COVID-19) deeply affected all forms of long-term care for older adults, highlighting infection control issues, provider and staff shortages, and other challenges. As a comparatively new, community-based long-term care option, the Program of All-Inclusive Care for the Elderly (PACE) faced unique challenges. This project investigated the impact of COVID-19 on operations in all PACE programs in one US state.DesignQualitative study.Setting and ParticipantsStructured interviews with administrators of all 12 PACE programs in North Carolina.MethodsInterviews were conducted December 2020 to January 2021 by trained interviewers over Zoom; they were transcribed, coded, and qualitatively analyzed using thematic analysis.ResultsReported COVID-19 infection rates among PACE participants for 2020 averaged 12.3 cases, 4.6 hospitalizations, and 1.9 deaths per 100 enrollees. Six themes emerged from analyses: new, unprecedented administrative challenges; insufficient access to and integration with other health care providers; reevaluation of the core PACE model, resulting in a transition to home-based care; reorientation to be more family-focused in care provision; implementation of new, creative strategies to address participant and family psychological and social well-being in the home; and major reconfiguration of staffing, including transitions to new and different roles and a concomitant effort to provide support and relief to staff.Conclusions and ImplicationsWhile facing many challenges that required major changes in care provision, PACE was successful in mounting a COVID-19 response that upheld safety, promoted the physical and mental well-being of participants, and responded to the needs of family caregivers. Administrators felt that, after the pandemic, the PACE service model is likely to remain more home-based and less reliant on the day center than in the past. As a result, PACE may have changed for the better and be well-positioned to play an expanded role in our evolving long-term care system.

The Program of All-Inclusive Care for the Elderly (PACE): The Innovative and Economically Viable Model of American Geriatric Care

Abstract The aim of this paper is to present a modern model of non-institutional geriatric care which operates in the US, called the Program of All-Inclusive Care for the Elderly (PACE). The economic consequences of an aging population with multiple chronic diseases are creating new solutions in the delivery of medical care. The author of the following article, based on review of PACE literature and her own experience, will focus on the history of the program, its nature, the social and economic advantages, and its efficacy in practice. In addition, the difficulties and limitations of PACE are analyzed, taking into account solutions for increased availability and popularization of the program on an international scale. Author currently works as an ANP at Mercy LIFE (Living Independently For Elders) of Alabama, a PACE organization, delivering primary care. She has identified a need for a model similar to PACE in the context of her own home country of Poland, where cultural and societal norms value caring for a loved one in his or her own household rather than institutional care. The author concludes that the PACE model would be indispensable as a geriatric healthcare model for countries outside the US experiencing a rapid growth in elderly patients resulting from demographic shifts common in the 21st century. Fast response is needed in creation of a similar program to PACE to prevent future economical consequences affecting medical care for the elderly.

Comparing PACE with a Medicaid‐Only Managed Long‐Term Care Plan: Health Outcomes Over Time

AbstractOutcomes from a partially integrated model of managed long‐term care—The VNS CHOICE program (VCP)—were compared to those from a fully capitated model—the Program of All‐Inclusive Care for the Elderly (PACE). A retrospective cohort design examined discharge, morbidity, and functional status for 3,200 individuals over 18 months. Although the two populations were close in average functional status, the PACE sample was sicker and more cognitively impaired. Higher rates of death were found in the PACE program (22 percent vs. 10 percent over 18 months) and a greater likelihood of decline in instrumental activities of daily living; higher functional disability scores (ADLs) predicted discharge in PACE but not in VCP. When propensity score stratification was used to compare like populations, the impact of program enrolment on outcomes became statistically insignificant, suggesting that a partially capitated model performs at least as well as the fully capitated PACE model.

Should Programs of All-Inclusive Care for the Elderly Use Community-Based Primary Care Physicians?

The program of All-inclusive Care for the Elderly (PACE) is a community-based, long-term care model designed for older adults that are nursing home eligible. Bound by original design and regulations, these programs have primarily utilized a center-based ("staff") primary care physician model. However, some believe that this might hinder expansion of the PACE model. In response to this concern, three PACE programs have explored the use of "community-based" primary care physicians (CBPCPs). In an attempt to evaluate the impact of this variation in the model, we surveyed the medical director, 2 community-based primary care physicians and 6 non-physician staff members at one of these sites. Responders generally support the use of CBPCPs as a useful and productive alternative way to expand PACE services to a wider audience of eligible patients. Because some staff members perceive that CBPCPs utilize hospital and NH services at a higher rate, continued education of both CBPCPs and staff members regarding the expectations from this relationship is needed.

Team Performance and Risk-Adjusted Health Outcomes in the Program of All-Inclusive Care for the Elderly (PACE)

The Program of All-Inclusive Care for the Elderly (PACE) is a community-based program providing primary, acute, and long-term care to frail elderly individuals. A central component of the PACE model is the interdisciplinary care team, which includes both professionals and non-professionals. The purpose of this study was to examine the association between the team's overall performance and the risk-adjusted health outcomes of program enrollees. The study included interdisciplinary teams in 26 PACE programs and 3,401 individuals enrolled in them. We combined information about individuals' health, functional, and mental status from DataPACE with an overall measure of team performance. We used multivariate regression techniques to test the hypothesis that better team performance is associated with better risk-adjusted health outcomes: survival and short-term (within 3 months of enrollment) and long-term (within 12 months of enrollment) improvements in functional status and in urinary incontinence. Team performance was significantly associated with better functional outcomes (both short and long term) and with better long-term urinary incontinence outcomes. There was no significant association with survival. This study provides empirical evidence for the relationship between team performance and patient outcomes in long-term care. It suggests that PACE programs can improve patient outcomes by improving the functioning of care teams.

The growing pains of integrated health care for the elderly: lessons from the expansion of PACE.

The early success of the demonstration Program of All-Inclusive Care for the Elderly (PACE) led to its designation as a permanent Medicare program in 1997. But the growth in the number of programs and enrollment has lagged and does not meet expectations. This article offers insights into the mechanisms influencing the expansion of PACE, from information obtained in interviews and surveys of administrators, medical directors, and financial officers in 27 PACE programs. Sixteen barriers to expansion were found, including competition, PACE model characteristics, poor understanding of the program among referral sources, and a lack of financing for expansion. This experience offers important lessons for providing integrated health care to the frail elderly.

Rural policy development: an NRHA and PACE association collaborative model.

The Program of All-Inclusive Care for the Elderly (PACE) offers a unique model of comprehensive care for frail, elderly people. To date, all of the PACE programs have been located in urban areas. Rural advocates and policymakers, however, believe the program may hold great promise for use in rural areas, which have higher percentages of elderly residents than urban areas. In 2002, the National Rural Health Association and the National PACE Association convened a meeting that brought together PACE experts, policymakers, and rural health care providers to examine PACE and its applicability for rural communities. The meeting participants concluded that there were many rural communities where the PACE model might not only be appropriate but also highly successful in caring for rural, frail, elderly people. This article examines the notion of expanding the PACE model to rural communities, including some of the barriers and some of the possible solutions that might make PACE a viable part of the rural health care delivery system.

Best Practice

Summary On Lok Senior Health Services provides community-based comprehensive care for the frail elderly and is the prototype of the PACE (Program of All-Inclusive Care for the Elderly) model of care. Comprehensive care includes all aspects of acute care and long term care under one capitated health delivery system. The cornerstone of care at On Lok is the interdisciplinary team that performs a comprehensive assessment of all participants at intake and at regular intervals after enrollment. The team consists of physician, social worker, nurse, physical therapist, occupational therapist, dietitian, home care nurse, geriatric aide, driver, recreation therapist and other specialists as needed. The team uses standardized instruments, develops treatment plans for each participant and meets at least four times per week to discuss cases. The case presented illustrates the benefits of the On Lok model of interdisciplinary care through the end of life of a frail elderly person.

The Program of All-Inclusive Care for the Elderly (PACE)

Summary This article examines the long-term care service system in the United States, its problems, and an improved long-term care model. Problematic quality of care in institutional settings and fragmentation of service coordination in community-based settings are two major issues in the traditional long-term care system. The Program of All-Inclusive Care for the Elderly (PACE) has been emerging since the 1970s to address these issues, particularly because most frail elders prefer community-based to institutional care. The Balanced Budget Act of 1997 made PACE a permanent provider type under Medicare and granted states the option of paying a capitation rate for PACE services under Medicaid. The PACE model is a managed long-term care system that provides frail elders alternatives to nursing home life. The PACE program's primary goals are to maximize each frail elderly participant's autonomy and continued community residence, and to provide quality care at a lower cost than Medicare, Medicaid, and private-pay participants, who pay in the traditional fee-for-service system. In exchange for Medicare and Medicaid fixed monthly payments for each participating frail elder, PACE service systems provide a continuum of long-term care services, including hospital and nursing home care, and bear full financial risk. Integration of acute and long-term care services in the PACE model allows care of frail elders with multiple problems by a single service organization that can provide a full range of services. PACE's range of services and organizational features are discussed.

Program of All-inclusive Care for the Elderly in 2002

This year is a pivotal time for the Program of All-inclusive Care for the Elderly (PACE) because the deadline for movement from demonstration project to permanent status is just around the corner for many sites. By late November, more than a dozen programs either will apply and be granted permanent provider designation or will cease to exist, once again altering the landscape of senior consumer options. After 3 decades of development, the PACE alternative has undeniably achieved success by both clinical and financial standards, but it does not lack some current and future challenges. HISTORY AND MODEL OVERVIEW PACE is an innovative, all-inclusive approach to caring for the frail elderly under a capitated reimbursement model. Originating in San Francisco in the early 1970s, the forerunner to today’s PACE model began in the ChineseAmerican community, wherein institutionalizing aging members in a nursing home was culturally unacceptable. On Lok (Cantonese for peaceful, happy abode) Senior Services developed a comprehensive, community-based approach to maintaining the frail elderly in their homes by applying multidisciplinary primary care within a structure that placed the adult day health center and related services (social, nutrition, recreational, medical, etc.) at its center and included home, acute, and extended care as relevant. By creatively applying the principles of health maintenance organizations (HMOs) to applicants deemed otherwise eligible for institutional care, On Lok has addressed the health care system issues affecting the elderly: fragmentation, expense, and lack of creativity in communitybased care. On Lok has maintained frail elders in their homes while enabling them to receive health care, recreation, and socialization through day centers and has managed risk through common sense preventive care. 1

The PACE Model: Description and Impressions of a Capitated Model of Long-Term Care for the Elderly

The Program of All-Inclusive Care for the Elderly (PACE) is an innovative model of comprehensive long-term medical and social services. The system receives monthly capitation payments from Medicare and Medicaid for clients who are nursing-home eligible. PACE was developed originally by On Lok Senior Health Services in San Francisco's Chinatown in the late 1970s. PACE is based upon the concept of maintaining the independence, autonomy and dignity of frail and disabled elders nearing the end of life (Sapir, 1996). The program's underlying principle is to keep participants (PACE program enrollees) in the community for as long as it remains medically, socially, and economically feasible (Shen and Iverson, 1992). There is also a strong intention to preserve and support the older adult's family unit.

Program of All-inclusive Care for the Elderly (PACE): an innovative model of integrated geriatric care and financing.

The Program of All-inclusive Care for the Elderly (PACE) is a long-term care delivery and financing innovation. A major goal of PACE is prevention of unnecessary use of hospital and nursing home care. PACE serves enrollees in day centers and clinics, their homes, hospitals and nursing homes. Beginning at On Lok in San Francisco, the PACE model has been successfully replicated across the country. In 1995, PACE was fully operational in 11 cities in nine states. To enroll in PACE, a person must be 55 years of age or older, be certified by the state as eligible for care in a nursing home and live in the program's defined geographical catchment area. PACE participants are ethnically diverse. In 1995, the average PACE enrollee was 80.0 years old and had an average of 7.8 medical conditions and 2.7 dependencies in Activities of Daily Living. A significant number have bladder incontinence (55%). Many enrollees (39%) live alone in the community, and 14% have no means of informal support. Medicare and Medicaid waivers allow delivery of services beyond the usual Medicare and Medicaid benefits. The PACE service delivery system is comprehensive, uses an interdisciplinary team for care management, and integrates primary and specialty medical care. PACE receives monthly capitation payments from Medicare and Medicaid. Patients ineligible for Medicaid pay privately. Outcomes of PACE programs have been positive. There has been steady census growth, good consumer satisfaction, reduction in use of institutional care, controlled utilization of medical services, and cost savings to public and private payers of care, including Medicare and Medicaid. However, starting up a PACE program requires substantial time and capital, and the model has not yet attracted large numbers of older middle income adults. The growing number of older people in the United States challenges healthcare providers and policy makers alike to provide high quality care in an environment of shrinking resources. The PACE model's comprehensiveness of health and social services, its cost-effective coordinated system of care delivery, and its method of integrated financing have wide applicability and appeal.

The PACE evaluation: initial findings.

As of mid-1994 there were nine replications of the On Lok model operating under dual capitation payments as sites in the Program of All-inclusive Care for the Elderly (PACE). A tenth site had begun operating under capitation, but was unable to remain viable. The present descriptive study documents the growth and development of the first seven of these sites, all that had been operating under capitation during 1992. Comparisons among these sites and with On Lok are presented in the areas of organizational structure, client characteristics, approaches to case management, service delivery options, and financing. There is considerable variability in the implementation of the PACE model. Combined Medicare and Medicaid capitation monthly payments range from $2,147 to $5,973. These seven PACE sites (excluding On Lok) served a total of 888 current clients at the end of 1992, after a cumulative 136 months of experience under capitation. The very slow enrollment rates may imply that the target clients are less enthusiastic about this model than are its architects. The client selection process may suggest niche-marketing or skimming, but not the full representation of the nursing home population in their states. Given both the slow enrollment and the niche-marketing (the benevolent term) or skimming (the pejorative term) that has occurred, caution about the long-term viability of the PACE model may be warranted.