Webinar: Caring for Older Adults with Complex Needs in the COVID-19 Pandemic: Lessons from PACE Innovations

Date and Time: June 30, 2020, 2:00 – 3:30 pm ET (11:00 am – 12:30 pm PT)
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The Program of All-Inclusive Care for the Elderly (PACE) is an evidence-based care model for older adults who meet a nursing-home level of care but live in community settings. These organizations blend funding from Medicare and Medicaid to integrate preventive, acute, and long-term care as well as services to address social needs. While many services are provided in PACE day centers, PACE organizations have adapted the delivery of services to meet patient needs during the COVID-19 pandemic.

This webinar, coordinated by the Better Care Playbook and the National PACE Association and made possible through support from the Seven Foundation Collaborative and West Health Policy Center, will highlight innovations adopted by PACE organizations during the pandemic to provide care for older adults with complex needs. Lessons shared will be broadly applicable to organizations serving vulnerable older adults in other settings during the pandemic as well, particularly through integrated health plan approaches. In addition, speakers will review state policy considerations to address the long-term needs of older adults requiring a nursing home level of care in the context of COVID-19.

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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. You can read this original post here.

COVID-19 Resources

Massachusetts PACE organizations take very seriously their commitment to maintaining the safety and security of all of the older adults, their families, and caregivers, as well as their staff, vendors, partners, and communities. Please follow the tabs below for links to resources with more information about some of the directives and resources PACE organizations are monitoring and following in their response to the COVID-19 crisis.

MassHealth Coronavirus Disease 2019 (COVID-19) Website

National PACE Association
GeroCentral COVID-19 Toolbox

Picking up the PACE for Elder Care

This was originally posted in CommonWealth Magazine. Read the full post here.

JAMES WOODBERRY, wheelchair bound and severely depressed, struggled to find hope. Overwhelmed by his condition and a complex health system, the 80-year-old Boston resident and his family faced a grim future. It was only after several failed attempts that he came across a program equipped to handle his needs — the Program of All Inclusive Care for the Elderly, or PACE.

PACE’s vision is simple, allowing seniors who qualify for nursing home level of care to age in place, at home. The program started as a federal demonstration project in 10 locations across the US in the late 1980s. By 1990, it became a permanent provider for individuals covered under both Medicare and Medicaid, the so-called “dual eligibles.” Structured as an adult day center, members have access to medications, primary care providers, social services and more, every day of the week.

This year, East Boston Neighborhood Health Center, one of the 10 pilot centers, celebrates 30 years of partnership with PACE. Called “Neighborhood PACE,” the East Boston health center’s program is Massachusetts’ longest running. Noteworthy is the housing component unique to Neighborhood PACE. The health center is a long-time partner of the East Boston Community Development Corporation. Together, they converted a former East Boston school into the first PACE center in Massachusetts to offer housing in 2007.
Despite the program’s long history, PACE operates under the radar. Manny Lopes, president and CEO of the East Boston health center and chairman of the board of Boston’s Public Health Commission, wants this to change.

PACE providers deliver integrated, patient-centered care that values personal choice. Dr. James Pedulla, medical director of East Boston’s PACE since its inception, knows that the care and time he devotes to patients is uncommon in most health care settings today. For him, a rewarding feature of the program is direct access to an interdisciplinary network. At PACE, everyone from drivers to clinical providers are part of the team.

Woodberry, a member of Neighborhood PACE for over 10 years, is one of the program’s biggest champions. For him, the program is a blessing. “I thank God I am in a place that I get the kind of care I get, the kind of caring that I get,” he said.

A former professional football player, Woodberry found his inability to walk a constant source of anguish. With the support of his PACE team, Woodberry regained his ability to walk and met his personal goal to play 18 holes of golf – twice.

A typical day for Woodberry starts with waking up in his own apartment and going down to the PACE center, which operates in the same building, for breakfast and conversation with other PACE enrollees. Woodberry gets his medications dispensed on site by one of the staff members, is able to participate in center activities, and meet with his primary care provider or another member of the clinical team.
For Woodberry, the adult day center model, which is unique to PACE, has been particularly influential. The decline in his physical health led him down a path of deep depression. He started to withdraw from his family and friends, feeling hopeless and defeated. Daily access to a space that facilitates social interaction and relationship building provided the strength and support he needed to recover. When asked what life would be like without PACE, Woodberry said matter-of-factly, “I’d be dead. What you see today is a helluva different person.”

The significant improvement in Woodberry’s mental and physical health is not lost on his family. Before discovering PACE, Woodberry’s daughter was prepared to uproot her life from New York City to Boston. Enrolling her father in PACE afforded her the choice to stay in New York while remaining involved in his care. In fact, once Woodberry attained the independence he was yearning for, it became easier for him to accept his daughter’s help. With direct access to the site nutritionist, Woodberry’s daughter can send him home cooked meals that comply with his recommended diet.
Family members of enrollees are invited to visit the facilities, communicate directly with the clinical care team, and attend regularly scheduled team meetings. Highlighting the impact that PACE has on family members, Lopes says, “We reduce some of their stress… allow them to go back to work or feel like they can go back to work without worrying about leaving mom or dad home alone.”

So why don’t more PACE programs exist? And why aren’t more seniors enrolled in PACE?

Assessing PACE’s success has been challenging due to its nature and population. Susan Ciccariello, director of coordinated care for the state’s Executive Office of Health and Human Services, has spent several years overseeing the PACE program. She acknowledges that the data on its effects are limited. The program’s impact on quality of life, mortality rates, and costs remains unclear. What is unequivocal however, is the growing interest in PACE both by state officials and seniors.

Currently, 129 PACE programs exist across 31 states, 8 in Massachusetts. The state saw a 5 percent increase in PACE enrollees in 2018. Nationwide, enrollment has increased 120 percent since 2011, now covering 45,000 enrollees. More recently, the federal government is allowing, for the first time, for-profit companies to become PACE providers.
Across the state, there has been a general trend towards coordinated health care models with the emergence of Senior Care Organizations, One Care plans (i.e., Medicare-Medicaid plans), and Accountable Care Organizations. These programs vary in eligibility, benefits, and funding source but share a similar goal to PACE — to provide comprehensive, integrated care that improves quality of life years for a growing number of seniors.

Despite existing for much longer, enrollment in PACE has lagged behind its counterparts. According to Ciccariello, a major reason for this large difference is access and awareness. Qualifying seniors are often not aware of the program or do not live in close proximity to a PACE site.

Recognizing these barriers, the Baker administration has established goals for streamlining the program and eliminating “PACE deserts.” The administration’s plans for the 2019-2020 calendar year include a review of costs and programming at each site, standardization of eligibility, enhancing awareness and access for qualifying residents, and establishing a more reliable system to collect data and create transparency among different program sites.

While no one size fits all solutions, stories like Woodberry’s are a good reminder that PACE has the potential to thrive, and scaling up the program is worthwhile. For Manny Lopes, the East Boston health center director, PACE is a symbol of what US health care should look like. He sees the expansion of PACE and models like it as an encouraging sign of a health care system that values the “voice and choice” of the people it serves.

Monica Vohra is a community health physician and advocate in Boston.

Don’t Miss the MassPACE 1st Annual Conference – September 18, 2019

Join us for a networking and learning experience as we celebrate the unique aspect of integrated care demonstrated by the Program of All-Inclusive Care for the Elderly (PACE). There are eight PACE plan providers across Massachusetts serving 5,000 consumers in the community. The MassPACE Association was formed in 2017 for the purposes of providing leadership and support for growth, access, quality, and success of PACE in the Commonwealth of Massachusetts. Come hear about innovations, best practices, and caring for yourself and others in this hands-on interactive conference. Registration includes, lunch, raffles, workshops, and the networking wine and cheese reception following the workshops.

The Vision of MassPACE is that PACE is accessible to every eligible consumer in the Commonwealth of Massachusetts and recognized as an extraordinarily innovative, accessible, valuable and effective model of care for individuals with significant healthcare needs.

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CONFERENCE AGENDA: SEPTEMBER 18, 2019

Registration 11:30 – 12:00

Lunch 12:00 – 1:30

  • PACE Participant Experience
  • Keynote and Panel Discussion: PACE IDT Innovations and Best Practices – Panel Moderator: Robin Lipson, Deputy Secretary, MA Executive Office of Elder Affairs
  • PACE Champion Award Presentation

Workshops – 1:30 – 4:30

  • TIPS – Team Improvement for Patient Safety – Involving the IDT in Quality Improvement, by Dr. Robert Schreiber, MD, AGSF, CMD, VP/Medical Director of Summit ElderCare and Michelle Malkoski, RN, Director of Quality and Risk, Summit ElderCare.
  • The Importance of Self-Care When Caring for our Participants, by Marjorie Sokoll, M.Ed., Director, Spirituality and Aging at Jewish Family & Children’s Services Greater Boston. Sponsored by Serenity Care.
  • Behavioral Health at PACE – A Psychotherapy and Psycopharmacology Perspective, by Philip Fleisher, LICSW, Lead Psychotherapist, Element Care, and Denise Boisvert, APRN, Lead Psychiatric Nurse Practitioner, Element Care.
  • Implementation Opportunities Under the PACE Final Rule, by Stephanie Castillo, BSN, Rn, Nurse Manager Uphams’ Corner Elder Service Plan, and Stefani Wood, PT, DPT, Senior Clinical and Rehab Manager, Uphams’ Corner Elder Service Plan
  • Caring for the Caregivers – the PACE Experience, by Mary Curlew, LICSW, Community Education and Training Specialist, at Jewish Family & Children’s Services Greater Boston. Sponsored by Serenity Care.

Networking Wine and Cheese Reception – 4:30 – 6:30

THANK YOU TO OUR SPONSORS:

PATRONStateServ/HospiceLink
AffiliatesCareVention, Comprehensive Mobile Care, Grane RX, Medline, Pharmastar, Vital Research

 

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