A Safe Alternative to Nursing Homes

In a 2018 blog post, the Institute for Healthcare Improvement (IHI) describes PACE as “safe alternative to nursing homes.” While posted in 2018, this post is more relevant than ever in light of the COVID-19 crisis.

More than 1.8 million seniors over the age of 65 in the United States live in supportive care facilities, but many would choose to remain at home if they could. The following excerpt from IHI’s No Place Like Home: Advancing the Safety of Care in the Home report presents a program that provides nursing home-level care to patients in their own homes.

To optimize the care of nursing home-eligible individuals receiving care at home or in a community-based setting, in 1990 the federal government began offering states Medicaid waivers to enable experimentation with value-based service models. The Program of All-Inclusive Care for the Elderly (PACE), an initiative originally developed by San Francisco’s On Lok Senior Health Services, was among the first programs. PACE aims to avoid nursing home placement by providing a broad range of care services to Medicare and Medicaid beneficiaries who clinically require a nursing home level of care. The program provides flexibility for caregivers; offers tailored services that manage the complex medical, functional, and social needs of frail elders; and promotes adherence to home safety standards.

Congress authorized 10 PACE replication sites in 1986 and codified PACE as a permanent Medicare program in the Balanced Budget Act of 1997. To date, 31 states offer PACE options to frail elders; 90 percent of PACE enrollees are eligible for both Medicare and Medicaid.

Description of the Program

For individuals who are deemed eligible for a nursing home level of care by their state’s administering agency, PACE offers an alternative option: living in their homes and communities while receiving coordinated, highly tailored health care services spanning the care continuum. Eligible seniors are assigned to a specific PACE organization that includes an interdisciplinary team comprising clinicians and support service providers. The interdisciplinary team is responsible for conducting initial and periodic participant assessments, performing care planning, and coordinating 24-hour care delivery.

The program includes these components:

• Initial and ongoing assessments by the interdisciplinary team
• PACE center services (such as adult day and social programs, primary and preventive care, restorative therapy, nutrition services and meals, pharmacy, social services)
• Transportation for participants
• Mental health care services
• Care coordination
• Assistance with activities of daily living
• Prescription medications
• Emergency services

How the Program Works

PACE organizations provide a wide range of services, including adult day programs, primary and preventive care, nutritional support, pharmacy services, social services, transportation, and other support services. Members of the interdisciplinary team coordinate services, based on a comprehensive baseline needs assessment. Within 30 days of enrollment, beneficiaries receive in-person assessments conducted by the interdisciplinary team, including an in-home assessment by a team member. Additional assessments are conducted at least every six months thereafter. Care is provided at PACE centers, at home, or in the community through contracts with other community-based providers. PACE center safety standards, outlined in federal regulations, address wheelchair accessibility, handrails, safe water temperatures, housekeeping chemical storage, cleanliness, and infection control protocols.

PACE Interdisciplinary Team Members of the PACE Interdisciplinary Team

At a minimum, the assessments address the following health and safety concerns:

• The home environment, including the ability to safely enter and leave the home
• Physical and cognitive function
• Medication use
• Participant and caregiver preferences for care, including advance care planning and participant goals of care (person-directed care)
• Socialization and availability of family support
• Current health status and treatment needs
• Nutritional status
• Participant behavior
• Psychosocial status
• Medical and dental status
• Participant language and cultural needs
• Based on the assessment findings, the interdisciplinary team creates a tailored care plan with a strong prevention component. If the participant is hospitalized or enters a skilled nursing facility, the interdisciplinary team often participates in clinical rounds that involve the participant.

The program is funded by a combination of sources, including Medicare, Medicaid, and private payers. Reimbursement is a fixed per member per month fee that covers the entire spectrum of participant-tailored services that care for the whole person. Because PACE assumes the full risk of the participant, the organization may find it cost-effective to provide interventions that are not traditionally covered by Medicare or Medicaid. For example, if the interdisciplinary team determines that a participant needs to have an air conditioner installed in his or her apartment perhaps because of a pulmonary condition, the program could cover that expense.

Program Results

• A 2014 federally supported evidence review suggested that PACE is cost-neutral relative to traditional Medicare. It also noted that PACE enrollees experience fewer hospitalizations than their counterparts in fee-for-service Medicare. Of the studies included in the review, the one with the strongest evidence rating found that PACE enrollees were nearly 30 percent less likely to be hospitalized than a matched comparison group.
• A 2016 Commonwealth Fund report suggested that the original (On Lok) PACE program’s 30-day readmissions rate was half that of other Medicare beneficiaries.
• A 2015 study found that PACE enrollees had a 31 percent lower risk of long-term nursing home admission than enrollees of Medicaid home- and community-based waiver programs, suggesting that PACE may help reduce long-term nursing home utilization.
  Approximately 93 percent of PACE participants report that they would recommend the program to a friend or relative.

Program Results

• A 2014 federally supported evidence review suggested that PACE is cost-neutral relative to traditional Medicare. It also noted that PACE enrollees experience fewer hospitalizations than their counterparts in fee-for-service Medicare. Of the studies included in the review, the one with the strongest evidence rating found that PACE enrollees were nearly 30 percent less likely to be hospitalized than a matched comparison group.
• A 2016 Commonwealth Fund report suggested that the original (On Lok) PACE program’s 30-day readmissions rate was half that of other Medicare beneficiaries.
• A 2015 study found that PACE enrollees had a 31 percent lower risk of long-term nursing home admission than enrollees of Medicaid home- and community-based waiver programs, suggesting that PACE may help reduce long-term nursing home utilization.
• Approximately 93 percent of PACE participants report that they would recommend the program to a friend or relative.
  To read other case studies and learn more about improving patient safety in the home, please download the No Place Like Home: Advancing the Safety of Care in the Home report.

This post was initially published by the IHI Multimedia Team on 10/4/2018.