Program Of All-Inclusive Care For The Elderly Participants 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.

Behavioral health integration in the Program of All-Inclusive Care for the Elderly (PACE): A scoping review.

The Program of All-inclusive Care for the Elderly (PACE) is a community-based care model that delivers collaborative care via an interdisciplinary team to meet the medical and social needs of older adults eligible for nursing home placement. Fifty-nine percent of PACE participants are reported to have at least one psychiatric disorder. PACE organizations (POs) function through an interdisciplinary model of care, but a behavioral health (BH) provider is not a mandated role on the interdisciplinary team. Published literature regarding how POs integrate and provide BH services is limited; however, the National PACE Association (NPA) and select POs have made significant contributions to behavioral health integration (BHI) efforts in PACE. PubMED, EMBASE, and PsycINFO were searched for articles published between January 2000 and June 2022; hand-searching was also conducted. Research articles and items involving BH components or programming in POs were included. Evidence of BH programming and initiatives at the organization and national level was summarized. This review reported on nine primary items addressing BH in POs from 2004 to 2022. It found evidence of successful BH initiatives in PACE and identified a gap of published information given an evident need for BH services in the PACE participant population. Findings also indicate the NPA works to advance BH integration in POs with a dedicated workgroup that has produced the NPA BH Toolkit, BH training webinar series, and a site coaching program. In the absence of PACE-specific BH delivery guidelines and guidance from the federal or state level for PACE programs, BH service inclusion has been developed unevenly across POs. Assessing the landscape of BH inclusion across POs is a step toward evidence-based and standardized inclusion of BH within the all-inclusive care model.

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.

Evaluating the Impact of Medication Risk Mitigation Services in Medically Complex Older Adults.

Adverse drug events (ADEs) represent an expensive societal burden that disproportionally affects older adults. Therefore, value-based organizations that provide care to older adults—such as the Program of All-Inclusive Care for the Elderly (PACE)—should be highly motivated to identify actual or potential ADEs to mitigate risks and avoid downstream costs. We sought to determine whether PACE participants receiving medication risk mitigation (MRM) services exhibit improvements in total healthcare costs and other outcomes compared to participants not receiving structured MRM. Data from 2545 PACE participants from 19 centers were obtained for the years 2018 and 2019. We compared the year-over-year changes in outcomes between patients not receiving (control) or receiving structured MRM services. Data were adjusted based on participant multimorbidity and geographic location. Our analyses demonstrate that costs in the MRM cohort exhibited a significantly smaller year-to-year increase compared to the control (MRM: USD 4386/participant/year [95% CI, USD 3040–5732] vs. no MRM: USD 9410/participant/year [95% CI, USD 7737–11,084]). Therefore, receipt of structured MRM services reduced total healthcare costs (p < 0.001) by USD 5024 per participant from 2018 to 2019. The large majority (75.8%) of the reduction involved facility-related expenditures (e.g., hospital admission, emergency department visits, skilled nursing). In sum, our findings suggest that structured MRM services can curb growing year-over-year healthcare costs for PACE participants.

POSA232 Evaluating Health Outcomes of Participants Enrolled in Program of All Inclusive Care for the Elderly (PACE) and Elderly Participants Enrolled in Other Care Giving Programs: A Scoping Review

Program of All-Inclusive Care for the Elderly (PACE) provides comprehensive medical and social services to community-dwelling older adults. Uncontrolled studies indicate PACE participants have positive outcomes. This scoping review aimed to review published studies that compared PACE outcomes to other similar programs.

VA home-based primary care interdisciplinary team structure varies with Veterans' needs, aligns with PACE regulation.

Interdisciplinary team (IDT) care is central to home-based primary care (HBPC) of frail elders. Traditionally, all HBPC disciplines managed a patient (Full IDT), a costly approach to maintain. The recent PACE (Program of All-inclusive Care for the Elderly) regulation provides for a flexible approach of annual assessments from a core team with involvement of additional disciplines dependent upon patient needs (Core+). Current Department of Veterans Affairs (VA) HBPC guidance specifies Full IDTs care for medically complex and functionally impaired Veterans similar to PACE participants. We evaluated whether VA HBPC has adopted the flexible structure of the PACE regulation, aligned to Veteran needs. Cross-sectional analysis. All 139 VA HBPC programs administered across 379 sites. About 55,173 Veterans enrolled in HBPC during fiscal year 2018. Patients' HBPC physician, nurse, psychologist/psychiatrist, social worker, therapist, dietitian, and pharmacist visits were grouped into interdisciplinary team types. Patient frailty was classified using VA HNHR v2 (High-Need High-Risk version 2, a measure of high, medium, and low risk of long-term institutionalization). Medical complexity was measured by clusters of impairment in the JEN frailty index (JFI). JFI clusters were validated by VA's Nosos measure to project cost and Care Assessment Need (CAN) measure of hospitalization and mortality risk. HBPC provided Full IDT care to 21%, Core+ care to 54%, and Home Health+ (HHA+) care (skilled home health services plus additional disciplines, without primary care) to 16% of Veterans. Team type was associated with medical complexity (X2 2863.5 [66 df], p < 0.0001). High-risk Veterans (72% of sample) were more likely to receive Full IDT care (X2 62.9, 1 df), p < 0.0001), while low-risk Veterans (28%) were more likely to receive HHA+ care (X2 314.8, 1 df, p < 0.0001). There is a strong association between HBPC team patterns and patient frailty, indicating tailoring of care to match Veteran needs.

Stakeholder and Data-Driven Fall Screen in a Program of All-Inclusive Care for the Elderly: Quality Improvement Initiative.

The Program of All-Inclusive Care for the Elderly (PACE) delivers community-based long-term care services to low-income, nursing home eligible adults. In the PACE population, one of the most common reasons for hospitalizations is falls. The purpose of this quality improvement study was to create a stakeholder-driven process for developing a fall risk screen and evaluate how well this process discriminated injurious and noninjurious fallers. The quality improvement design was a prospective, longitudinal data collection for 5 PACE programs in Colorado. Physical therapists collected the Short Physical Performance Battery (SPPB) on participants at least annually. The Kotter practice change framework guided the processes for practice and organizational change in developing and implementing a fall screen. An iterative, stakeholder, and data-driven process allowed our team of researchers and a PACE program to establish a fall risk screen to stratify PACE participants. We provided feedback to PACE staff regarding screening rates and results on discrimination of faller status to promote continued uptake of screening and discussion regarding next steps. Rehabilitation therapists screened 66% of the PACE population, and participants were stratified into high risk (1-7 points) or low risk (8-12 points) based on the SPPB. Participants with low SPPB scores had 79% greater risk of a fall (risk ratio [RR] = 1.8; 95% confidence interval [CI], 1.5-2.1) and 86% greater risk of an injurious fall (RR = 1.9; 95% CI, 1.4-2.4), compared with those with high SPPB scores. Our study describes a collaboration to address fall rates in a PACE population. Program of All-Inclusive Care for the Elderly clinicians can use the identified cut-offs to stratify PACE populations at risk for falls and allocate scarce rehabilitation resources efficiently to best serve participants at highest risk, while using less resource-intensive interventions for those at lower risk.

Cytochrome P450 (CYP450) Interactions Involving Atypical Antipsychotics are Common in Community-Dwelling Older Adults Treated for Behavioral and Psychological Symptoms of Dementia.

Treatment of behavioral and psychological symptoms of dementia (BPSD) and comorbidities often necessitates the concomitant use of antipsychotics and non-antipsychotic drugs, thereby potentiating the risk for drug–drug interactions (DDIs). The primary objective of our study was to identify potentially clinically relevant cytochrome P450 (CYP)-mediated DDIs involving antipsychotics among participants enrolled in the Program of All-Inclusive Care for the Elderly (PACE) with BPSD. Additionally, we wanted to determine the prevalence of antipsychotic use in this population. The study included 10,001 PACE participants. The practice setting used a proprietary clinical decision support system (CDSS) to analyze simultaneous multidrug interactions. A retrospective analysis of pharmacy claims data was conducted to identify DDIs involving antipsychotics prescribed for BPSD, using snapshots of medication profiles paired with the CDSS. Of the participants who met inclusion criteria, 1190 (11.9%) were prescribed an antipsychotic; of those, 1071 (90.0%) were prescribed an atypical antipsychotic. Aripiprazole commonly caused (being a perpetrator drug 94.6% of the time) potential DDIs with antidepressants (e.g., duloxetine, venlafaxine, mirtazapine), opioids (e.g., hydrocodone, oxycodone, tramadol) and metoprolol via the CYP2D6 isoform. Risperidone commonly caused (85.7%) potential DDIs with donepezil, lamotrigine and trazodone via the CYP3A4 isoform. Quetiapine exclusively suffered (100%) from potential DDIs with amlodipine, buspirone, omeprazole or topiramate via the CYP3A4 isoform. Antipsychotics are commonly prescribed to PACE participants for BPSD treatment and they may interact with other drugs used to treat comorbidities. A thorough review of concomitant medications will help mitigate the likelihood of potentially dangerous CYP-mediated DDIs involving antipsychotics.

Structured Telephone Support Intervention: Improved Heart Failure Outcomes.

BackgroundPresently, 6.5 million Americans are living with heart failure (HF). These patients are expected to follow a complex self-management regimen at home. Several demographic and psychosocial factors limit patients with HF in following the prescribed self-management recommendations at home. Poor self-care is associated with increased hospital readmissions. Under the Affordable Care Act, there are financial implications related to hospital readmissions for hospitals and programs such as the Program of All-Inclusive Care for the Elderly (PACE) in Pinellas County, Florida. Previous studies and systematic reviews demonstrated improvement in self-management and quality of life (QoL) in patients with HF with structured telephone support (STS) and SMS text messaging.ObjectiveThis study aimed to evaluate the effects of STS and SMS on self-care, knowledge, medication adherence, and QoL of patients with HF.MethodsA prospective quality improvement project using a pre-post design was implemented. Data were collected at baseline, 30 days, and 3 months from 51 patients with HF who were enrolled in PACE in Pinellas County, Florida. All participants received STS and SMS for 30 days. The feasibility and sustained benefit of using STS and SMS was assessed at a 3-month follow-up.ResultsA paired t test was used to compare the mean difference in HF outcomes at the baseline and 30-day follow-up, which demonstrated improved HF self-care maintenance (t 49=0.66; P=.01), HF knowledge (t 49=0.71; P=.01), medication adherence (t 49=0.92; P=.01), and physical and mental health measured using Short-Form-12 (SF-12; t 49=0.81; P=.01). The results also demonstrated the sustained benefit with improved HF self-care maintenance, self-care management, self-care confidence, knowledge, medication adherence, and physical and mental health (SF-12) at 3 months with P<.05 for all outcomes. Living status and social support had a strong correlation with HF outcomes. Younger participants (aged less than 65 years) performed extremely well compared with older adults.ConclusionsSTS and SMS were feasible to use among PACE participants with sustained benefits at 3 months. Implementing STS and SMS may serve as viable options to improve HF outcomes. Improving outcomes with HF affects hospital systems and the agencies that monitor and provide care for outpatients and those in independent or assisted-living facilities. Investigating viable options and support for implementation will improve outcomes.

Medication-related problems encountered in the Program of All-Inclusive Care for the Elderly: An observational study

ObjectiveTo evaluate pharmacist-encountered medication-related problems (MRPs) among the participants of the Program of All-Inclusive Care for the Elderly (PACE). DesignThis was a retrospective analysis of proprietary pharmacy records detailing pharmacist encounters with PACE clinical staff. Setting and participantsA national provider of pharmacy services to more than 75 PACE organizations. In total, 1057 PACE participants at 69 PACE sites across the United States with documented pharmacist encounters between March and May 2018. Outcome measuresMRPs were classified using the Hepler-Strand taxonomy, and pharmacists’ recommendations made to prescribers to resolve these MRPs were classified using a modified Hoth taxonomy. In addition, pharmacists’ communication methods and prescribers’ responses were analyzed. ResultsOverall, 2004 MRPs were encountered. The most frequent MRPs identified were related to medication safety concerns, including drug interactions (720, 35.9%), adverse drug reactions (ADRs, 356, 17.8%), high doses (270, 13.5%), and unindicated drugs (252, 12.6%). Drug interactions frequently involved competitive inhibition, 3 or more drugs, opioids, anticoagulants, antiplatelets, and antidepressants. Deprescribe medication (561, 24.8%), start alternative therapy (553, 24.4%), change doses (457, 20.2%), and monitor (243, 10.7%) were the top 4 types of recommendations made by pharmacists. Among 1730 responses obtained from PACE prescribers, 78.1% (n = 1351) of pharmacists’ recommendations were accepted. Compared with electronic communication, telephonic communication was associated with more acceptance and less prescriber nonresponse (χ2 = 78.5, P < 0.001). ConclusionPharmacists identified a substantial number of MRPs in PACE, especially those related to medication safety such as drug interactions and ADRs. In this practice setting, significant collaboration occured between pharmacists and PACE prescribers, as evidenced by the rate of prescribers’ acceptance of pharmacists’ recommendations. Further research is needed to fully evaluate the economic, clinical, and humanistic outcomes associated with pharmacists’ encounters in PACE.

Genetic variants and interactions from a pharmacist-led pharmacogenomics service for PACE.

Aim: Evaluate results of pharmacogenomics testing for participants enrolled in the Program of All-inclusive Care for the Elderly (PACE). Materials & methods: A convenience sample of 100 participants from the PHARM-GENOME-PACE study. Genetic variants were determined by pharmacogenomics testing. Drug-gene interactions (DGIs), drug-drug-gene interactions (DDGIs) and phenoconversions were interrogated from a clinical decision support system. Results: In total, 146 genetic variants, 169 DGIs and 125 DDGIs were detected. DGIs and DDGIs occurred most commonly with the CYP2D6 gene (36.1 and 39.2%, respectively). There were 280 instances of phenoconversions; majority (62.9%) affecting the CYP3A4 isoenzyme. Conclusion: Prevalence of exposures to DGIs and DDGIs among PACE participants is high. Pharmacists using aclinical decision support system can support PACE practitioners with assessing multidrug simultaneous interactions. Clinical trial registration: NCT03257605.

Dementia, Comorbidity, and Physical Function in the Program of All-Inclusive Care for the Elderly.

Participants in the Program of All-Inclusive Care for the Elderly (PACE) are a unique clinical population of medically complex and highly disabled older adults who qualify for nursing home level care but receive services in the community. A main goal of PACE programs is to prevent further declines in physical function that may necessitate costly institutionalization. This study evaluates how multimorbidity and dementia impact both self-selected gait speed and Timed Up and Go (TUG) in this population. This study was a cross-sectional design. Sociodemographic information, physical function, comorbidity data, and dementia status on 525 PACE participants were extracted from a quality improvement database. Separate univariable and multivariable linear regression models were used to evaluate the impact of comorbidity status and dementia on gait speed and TUG time. PACE participants overall have a high degree of functional disability, with an average gait speed of 0.66 m/s, an average Short Physical Performance Battery score of 6.0/12, and an average TUG time of nearly 20 s. In the univariable analysis, a higher number of comorbidities and a diagnosis of dementia were associated with greater limitation for gait speed and TUG time. After adjusting for age, sex, strength, and balance, each additional comorbidity was independently associated with 0.015 m/s slower gait speed, as well as a 3.5% increase in TUG time for PACE participants with dementia. Ambulatory PACE participants have average levels of physical function that are dangerously close to thresholds thought to indicate vulnerability for further disability development, hospitalization, and nursing home admission. Both dementia and comorbidity burden are associated with declines in physical function, and the interaction between these risk factors is a telling indicator to functional decline in higher-level ambulatory tasks. PACE program clinicians can use this information to better identify participants at risk for limited physical function. Further research should investigate consequences of functional decline and determine optimal intervention strategies for PACE participants with functional impairments.

Prevalence of Anticholinergic Medication Use in the Program of All-Inclusive Care for the Elderly.

Evaluate the prevalence of anticholinergic medication use in the Program of All-Inclusive Care for the Elderly (PACE). Cross-sectional, retrospective chart review. The Basics at Jan Werner PACE, Amarillo, Texas. PACE participants (n = 128) and long-term care residents (n = 105) 65 years of age and older. The primary outcome was percentage of prescribed medications with anticholinergic properties and risk factors associated with prescribing: study site, gender, race, age, and creatinine clearance. Anticholinergic medication prescribing was significantly lower in the PACE program (2.3% of total medications vs. 3.9%; P < 0.05) as well as total medication use (12.1 medications per subject vs. 20.8; P < 0.05 in the long-term care environment). Only the long-term care study site had a significant association with anticholinergic prescribing (odds ratio = 5.04, confidence interval 2.71-9.38). PACE participants also had lower Anticholinergic Risk Scale scores (score of 0, 60.2% PACE vs. 16.2%), reduced fall rates (23.8 per month PACE vs. 66.9), and similar hospitalization rates (5.4 per month PACE vs. 5.7). PACE participants were prescribed fewer medications and had lower anticholinergic burden, which potentially lowers their risk of adverse effects. These data support the PACE interdisciplinary model by demonstrating the benefit of team care in appropriate use of medications. It provides a potential blueprint to organizations aimed at reducing potentially inappropriate medication prescribing in older adults.

The Ins and Outs of Pharmacy Services at a Program of All-Inclusive Care for the Elderly

A program of all-inclusive care for the elderly (PACE) is a medical care model currently used in 75 clinical settings across the country. The goal of the model is to allow a participant to live independently in the community as an alternative to living in a long-term care facility. To be eligible for enrollment, participants must meet the following criteria: 55 years of age or older, at a nursing-facility level of care (as determined by the state), living in the PACE service area, and can be safely cared for in the community at the time of enrollment. Once enrolled, care for the participants is provided by an interdisciplinary team (IDT) comprising several medical professionals, including pharmacists. Although not a required member of the IDT, pharmacists can be instrumental to the care of PACE participants. When available, pharmacy services can be divided into dispensing pharmacy services--providing onsite access to medications--and consultant clinical pharmacy services--providing consultant, acute, and chronic disease management, education, administration, and academic/scholarly services. With a lack of current pharmacy services at many PACE organizations and the potential for expansion of pharmacy services, pharmacists can be beneficial for both the IDT and participants in a PACE setting.

Medical Care Cost of Medicare/Medicaid Beneficiaries with Vision Loss

Purpose: To assess the impact of vision loss on healthcare cost for patients with Medicaid and Medicare and whether these costs are adequately captured by Medicare hierarchical condition categories (HCC) risk adjustment methodology. Data Sources: The public use data set of the Program of All-Inclusive Care for the Elderly (PACE) for 1994–1998, and the Medicare 5% Sample datasets for 2003 and 2004. Methods: For the first analysis, up to five years of PACE data for each individual was used to calculate HCC scores (n = 3,459). For the second analysis, claim or encounter data from Medicare Fee-for-Service (FFS) and Medicare Advantage (MA) were used to estimate the cost for each beneficiary in the upcoming payment year (n = 2,108). Results: The increase in medical cost risk overall for visually impaired PACE participants was 10%, increasing to 13% for the non-institutionalized, community-based cohort, but PACE participants in nursing homes with vision loss did not generally result in increased costs. In the Medicare 5% sample, the HCC model under-predicts costs by about 17%. Conclusion: Our analyses provide evidence that healthcare cost risk attributable to vision loss is not adequately captured by Medicare HCC risk adjustment methodology. We hypothesize this is due to additional morbidity and treatment patterns associated with visual impairment.

Characteristics Predicting Nursing Home Admission in the Program of All-Inclusive Care for Elderly People

This study determined overall risk and predictors of long-term nursing home admission within the Program of All-Inclusive Care for the Elderly (PACE). DataPACE records for 4,646 participants aged 55 years or older who were enrolled in 12 Medicare- and Medicaid-capitated PACE programs during the period from June 1, 1990, to June 30, 1998, were obtained. Participants were enrolled for at least 30 days and had baseline evaluations within 30 days of enrollment. Cox proportional hazard models predicting an outcome of nursing home admission of 30 days or longer were estimated. The cumulative risk of admission to nursing homes for 30 days or longer was 14.9% within 3 years. Individuals enrolled from a nursing home were at very high risk for future admission, with a relative risk of 5.20 when compared with those living alone. Among individuals enrolled in PACE from the community, age, instrumental activity of daily living dependence, and bowel incontinence were predictive of subsequent nursing home admission. Asians and Blacks had a lower risk of institutionalization than Whites. However, other characteristics were not independently predictive of institutionalization, namely poor cognitive status, number of chronic conditions, activity of daily living deficits, urinary incontinence, several behavioral disturbances, and duration of program operation. Before adjusting for other variables, there was substantial site variability in risk of nursing home admission; this decreased considerably after other characteristics were adjusted for. Despite the fact that 100% of the PACE participants were nursing home certifiable, the risk of being admitted to a nursing home long term following enrollment from the community is low. The presence of some reversible risk factors may have implications for early intervention to reduce risk further, although the effect of these interventions is likely to be modest. Individuals who received long-term care in a nursing home prior to enrollment in PACE remain at high risk of readmission, despite the availability of comprehensive services.

Predicting place of death in the program of all-inclusive care for the elderly (PACE): participant versus program characteristics.

To assess the relationship between participant-specific and program-specific characteristics and the place of death in the Program of All-Inclusive Care for the Elderly (PACE). A retrospective, population-based, cross-sectional study. PACE is a community-based managed care model serving a frail, nursing home-eligible population of Medicare beneficiaries. Two thousand two hundred sixty-three PACE decedents from 12 sites that were fully capitated for Medicare and Medicaid by mid-1997. Participant-specific characteristics include the range of demographic, functional, and cognitive status; skilled care needs; medical conditions; and advance care directives measures. The PACE site-specific indicator was also included to assess the effect of program sites on place of death. Bivariate, logistic, and multinomial logit models were employed. The probability of death at home is twice as great (45%) for PACE program participants as for the general population of older Americans. Twenty-one percent of PACE participants die in hospitals, compared with 53% of Medicare beneficiaries. Participants who are older and live in the community have a significantly greater (P< .05) probability of dying at home than does an average PACE enrollee. Those with a do-not-resuscitate order are 7.4% less likely to die in the hospital than are those without. PACE participants with a live-in informal caregiver are 10.3% (P< .05) less likely to die at home than those without a caregiver. When all participant characteristics were accounted for, there remained significant variation in the place of death by PACE plan. We found the least amount of site-specific variation in deaths occurring at home and the most variation in deaths occurring in hospitals. Nationally, the low rate of home death has prompted some to conclude that it is unlikely that we will, as a society, decide to take our dying older people back into our homes. The PACE experience suggests that it is possible to modify this trend. The results indicate that patient and program characteristics are both important in predicting the place of death. The variation across PACE sites suggests that an opportunity for narrowing these gaps, and reducing the proportion of hospital deaths, exists. The PACE end-of-life practice style could potentially be applied to other populations and may have important public policy implications.

Hospitalization in the Program of All-Inclusive Care for the Elderly (PACE): rates, concomitants, and predictors.

The Program of All-Inclusive Care for the Elderly (PACE) replicates the model of comprehensive, community-based geriatric care pioneered by On Lok, that enrolls frail older adults who meet states' criteria for nursing home care, and that uses interdisciplinary teams to assess the participants and to deliver care in appropriate settings. As managed care, PACE receives capitated payment from Medicare and Medicaid. Thus, PACE's fiscal incentives are thought to be aligned with the goals of optimizing health, function, and quality of life through the delivery of effective primary, preventive, restorative, supportive, and palliative care and through the avoidance of inappropriate and expensive hospital and nursing home utilization. To describe short-term hospital utilization, hospital discharge diagnoses, time from enrollment to first hospitalization and its clinical predictors, and hospitalization in relation to mortality among PACE participants. Data on short-term hospitalization and participants were recovered from PACE's minimum data set. Bed use was evaluated in annual cross-sections of current participants. Primary hospital discharge diagnoses were available for discharges from September 1, 1993 through March 31, 1997. The time from enrollment to hospitalization was calculated for the participants (n = 5478) who were admitted between January 1, 1990 and March 31, 1997. The characteristics of this inception cohort were used to develop a Cox regression model of hospitalization. All PACE deaths were identified and the place of death was recovered, together with the medical records used in the hospital during PACE enrollment or 6 months before death. Bed-days per 1,000 PACE participants per year were comparable with the general Medicare (fee-for-service) population, at 2,046 (in 1998) versus 2014 (in 1997) despite the greater morbidity and disability for PACE participants, as reflected in their enrollment characteristics and primary hospital discharge diagnoses. The time to hospitalization was 773 days (median); 95% confidence interval, 725, 814, and was predicted by disease, treatment, social and demographic factors. Whereas 8% of PACE deaths occurred in acute hospitals, less than one-third of the decedents spent any time in the hospital in the 6-month interval before death. Overall, short-term hospital utilization among PACE participants is low in contrast with that for other older and disabled populations. Participant predictors of hospitalization in PACE are generally consistent with other studies in older clinical and community populations. Both utilization and risk vary considerably across PACE sites, independent of participant-level risk factors, hence suggesting that further investigation is required to study PACE's management of acute illness and hospitalization decisions. Critical to maintaining PACE's success is an understanding of the independent impact of the organization and the environment of health care on this management.

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.