PACE: Program for All-Inclusive Care for the Elderly

PACE: Program for All-Inclusive Care for the ElderlyMark A. Newbrough, MDMedical Director, Blue Ridge PACEAssoc. Prof., Section Head for GeriatricsUniversity of Virginia

DisclosureBlue Ridge PACE is a new program serving Charlottesville, and surrounding counties of Albemarle, Fluvanna, Louisa, Greene, and NelsonI am medical director for Blue Ridge PACEUVA, JABA, and Riverside Health Systems are partners in Blue Ridge PACEObjectivesDescribe the key aspects of the PACE model of careDescribe the proven benefits of the PACE model of careExplain the basic components of how the PACE Interdisciplinary Team interacts with other providers, including inpatient providers to comprehensively meet the needs of frail older adultsMr. JonesMr. Jones is an 87 year old patient that has seen you in your practice for the past 8 years. His 54 year old daughter provides 24 hour care for him in her home. She has had to quit her job, and her marriage is threatened by the demands of caregiving. She is no longer able to take her father out to church, and despite the fact that you have worked tirelessly with the social worker to provide additional support for the patient and his family, she fears that she may have to place her father in a nursing home. She asks if you know anything about the new PACE program here in town. What is PACE?According to CMS website:Medicare program for older adults and people over age 55 living with disabilitiesProvides community-based care and services to people who otherwise need nursing home level of careCreated to provide participants, families, caregivers, and health professionals flexibility to meet the health needs of participants and help them to continue living in the communityCare is provided and coordinated by an interdisciplinary team (IDT) of health professionalsCMS Quick Facts (cont.)PACE provides all the care and services covered by Medicare and Medicaid, as authorized by the IDT, as well as additional medically-necessary care and services not covered by Medicare and Medicaid.True participant centered carePACE programs are provider sponsored health plans: This means your PACE doctor and other care providers are also the people who work with you to make decisions about your care.Preventive care is covered and encouragedPACE Services include:Primary care (including physician and nursing care)Hospital CareMedical Specialty ServicesPrescription DrugsNursing Home CareEmergency ServicesHome CarePhysical TherapyOccupational TherapyAdult Day CareRecreational TherapyMealsDentistryNutritional CounselingSocial ServicesLaboratory / X-ray servicesSocial Work CounselingTransportationWho is Eligible for PACE?Age 55 and olderLong term nursing care eligible (but only 7% of PACE participants nationally actually live in nursing homes)Live in a PACE service areaAble to live safely in the community at the time of enrollment in PACELong Term Nursing EligibilityUAI: Uniform Assessment InstrumentCriteria:Dependent in 2-4 ADLsPLUS semi-dependent OR dependent in behavior AND orientationPLUS semi-dependent in joint motion OR medication administrationDependent in 5-7 ADLsPLUS dependent in mobilitySemi-dependent in 2-7 ADLsPLUS dependent in mobilityPLUS dependent in behavior AND orientation

History of PACE (NPA website)On Lok (Cantonese for peaceful, happy abode)

1971: Outlined as comprehensive system of care based on the British day hospital model1973: Opens one of the nations first adult centers in San Francisco1974: Begins receiving Medicaid reimbursement for adult cay health servicesPACE History (cont.)1975: Adds social day care center and includes in-home care, home-delivered meals and housing assistance program1979: 4 year Dept. of HHS grant to develop a consolidated model of delivering care to person with long term care needs1983: Develops new financing system that pays a fixed per member per month payment1986: Federal legislation extends new financing system and allows 10 additional organizations to replicate mode

Interim regulations published in 1999, but final regulation published in November, 200611PACE History (cont.)1986: Federal legislation extends new financing system and allows 10 additional organizations to replicate model1987: Robert Wood Johnson support1990: First PACE programs received Medicare and Medicaid waivers to operate the program1997: Balance Budget Act of 1997 establishes PACE model as permanently recognized provider type under Medicare and Medicaid programs

1997 Review (1)Findings:In 1995, PACE fully operational in 11 cities, nine statesAverage enrollee: 80 years old, 7.8 medical conditions, an 2.7 dependencies in Activities of Daily Living55% with urinary incontinence39% living alone, and 14% with no informal supportReductions in use of institutional care w/ controlled utilization of medical servicesCost savings to Medicare and MedicaidPACE IDT Function is Critical (3) Findings:Teams must include: primary care physician, nurse, social worker, PT, OT, recreational therapy, dieticians, PACE day center coordinator, home care coordinators, personal care attendants, and driversPrior studies had shown that patients cared for by teams have better survival, functional, and cognitive outcomes, as well as lower institutionalization ratesThis study looked at PACE teams for variationTeam Function (cont.)Attendance at team meetings varies according to participant being discussedTeam meetings typically run by a facilitatorValidated team performance tool compared to rates of urinary incontinence and ADL function at 3 & 12 months Statistically significant improvement in ADLs at 3 months an 12 months with higher functioning teams, and urinary incontinence at 12 monthsNo association with mortality ratesNote: sites with higher nursing FTE had lower mortality but not better ADL or UI outcomes2004 & 2009 Health Policy ReviewsFindings:Lower rates of nursing home admission, shorter hospital stays, lower mortality rates, and better self-reported healthCosts for PACE enrollees are 16-38% lower than Medicare fee-for-service costs for a frail elderly population5-15% lower costs than for comparable Medicaid beneficiariesMore likely to die at home

Health Policy articles (cont.)Challenges: Cost and Model structureMany older adults not keen on adult day centerReluctance to change doctorExpensive start up costs, and costly to expandFor profit providers have not entered marketChallenges with state support: concern over Medicaid budgetsUnaffordable for middle income individuals2013 Update: Medicaid costs (5)Waiver cohort least impaired to NH most impairedPACE cohort was a blend between waiver and NH when looking at burden of illnessExpected Medicaid annual costs for PACE type participants in alternative long-term care was $36,620Actual Medicaid capitation to PACE was $27, 648 (28% below the lower limit of predicted fee-for-service payments)PACE in VirginiaRapid growth since mid-2000s in Virginia13 Centers in: Stone Gap, Newport News, Cedar Bluff, Richmond, Fairfax, Hampton, Roanoke, Lynchburg, Virginia Beach, Portsmouth, Farmville, and PetersburgBlue Ridge PACE is the 14th center in Virginia, our program opened March 1, 2014 Blue Ridge PACENon-profit corporation formed by three partners:UVA Health SystemsJefferson Area Board on Aging (JABA)Riverside Health SystemsLocated at:1335 Carlton Ave.Charlottesville, VA 22902434-529-1300www.blueridgepace.org

Mr. Jones RevisitedBRP participant for 18 months, he has had three comprehensive team assessments, the last one 3 weeks agoReceives 14 hrs. of home care weeklyVisits PACE center 5 days per weekParticipates in activities at the centerDaughter has returned to work, relationships have stabilized

Mr. Jones Becomes IllBoth his home aide and driver notice he appears ill one morning After a short discussion in the morning IDT meeting, he is seen by nurse and doctor in PACE clinic same day, with normal WBC and negative CXR done, but fever and cough presentGoals of care reviewed with family, and decision made to try oral antibiotics and observe closelyAntibiotics started

Mr. Jones Follow-upHe is seen again the next day in the PACE clinicTolerating antibiotics, food, and water, no noticeable deterioration from previous dayThat night becomes acutely short of breath, becomes frightened, and so does his familyThey contact PACE nurse on call, who also consults with physicianDue to rural home location, and acuteness of SOB, decision made to send to ER ER StayLabs and CXR confirm diagnosis of pneumonia, but breathing calms down with O2 supplementationFamily is unsure of next steps, and not sure they can manage patient at homeHospital team and PACE physician discuss case, and decide to admit Mr. JonesComplete medication list and summary providedThe next day, both the Mr. Jones nurse and the physician check on him and assist with care planningNext DayPACE team meets with family, and proposes plan of care:Discharge from hospital to SNF for course of IV antibiotics and observation (no 3 day stay required)Restorative therapies will assess him at SNF, and determine need for therapyAdditional discussions with family depending on clinical courseDischarge from SNF to home after only 3 days, with home evaluation and clinic evaluation within 24 hours of dischargePACE SummaryComprehensive model of medical and social careTeam based, participant centeredFocus on keeping people in their homeProvide needed care at lowest cost level of careIncreased flexibility compared to usual Medicare / Medicaid fee-for-service careA community based partner who can help care for our oldest and most frail patients, and will help care for them wherever they may be

ReferencesEng, Catherine; Pedulla, James; Eleazer, Paul G.; McCann, Robert; and Fox, Norris. Program of All-inclusive Care for the Elderly (PACE): An Innovative Model of Integrated Geriatric Care and Financing, JAGS Vol. 45, No. 2, Feb 1997, pp. 223-232, 244Gross, Diane L., et al, The Growing Pains of Integrated Health Care for the Elderly: Lessons from the Expansion of PACE, The Milbank Quarterly, 2004, Vol. 82, No. 2, pp. 257-82Mukamel, Dana B., et al, Team Performance and Risk-Adjusted Health Outcomes in the Program of All-Inclusive Care for the Elderly (PACE), The Gerontologist, 2006, Vol 46, No. 2, pp. 227-237References (cont.)Petigara, Tanaz and Gerard Anderson. Program of All-Inclusive Care for the Elderly. Health Policy Monitor, April 2009 http://www.hpm.org/en/Downloads/Health_Policy_Developments.htmlWieland, Darryl, et al, Does Medicaid Pay More to a Program of All-Inclusive Care for the Elderly (PACE) Than for Fee-for-Service Long-term Care?, J of Gerontology, A Biol Sci Med Sci, 2013 January: 68(1): 47-55