PACE: Is This the Future of Long-Term Care?

Nursing Homes, Oct, 2001 by Robert Greenwood

The alternate site leader is gaining respect as a model of long-term care change - and new opportunities for nursing homes

At the most recent National PAGE Association Spring Policy Conference, former HCFA administrator Bruce Vladeck posed an interesting question for his audience: Are Programs of All inclusive Care for the Elderly (PACE) the breakthrough model that will revolutionize the way we care for frail older adults in the 21st century? Or are they nice boutique programs with some interesting features that perhaps might influence "mainstream" long-term care providers?

While Vladeck concluded that the odds were stacked against any revolution in long-term care, he expressed hope that the aging baby-boom population would provide an opportunity to drastically change the way care for older Americans is organized, paid for and delivered.

A PACE program uses care coordination and capitated financing to provide a full range of preventive, primary, acute and long-term care services across a variety of settings with the goal of enabling frail older individuals to live as independently as possible. Developing one could be a way healthcare organizations can prepare themselves to meet the healthcare needs and consumer demands of the 21St century. And nursing homes, which on the surface would appear to lose out on census in such an arrangement, needn't feel left out.

James Introne, president of Loretto Health System, maintains that implementing the PACE program in Syracuse, New York, is having a revolutionary effect on his long-term care organization. Syracuse is a community that has experienced a growing aging demographic similar to what America as a whole will experience in the future. Introne observes, "For decades our nursing home has been at the center of our organization. Everything we have done, from developing affordable senior housing to community services, has been with the goal of extending our nursing home into the community. With PACE, our thinking has totally changed. We are now planning to build PACE sites throughout Syracuse. Instead of a continuum of care, PACE is becoming the central hub of our organization. In the future, our housing, home care, nursing home and other programs will provide settings and services that enable us to serve our PACE participants in the most appropriate environment."

Introne says that because the emphasis of PACE is the coordination of preventive, primary, acute and long-term care across all settings, the system is no longer fragmented for PACE participants. "From support of informal caregiving in the community to nursing home placement, PACE allows us to leverage our existing facilities and expertise to serve many more people than we could under the traditional fee-for-service system."

PACE Background

How did this futuristic concept evolve? The PACE model of care was created in the early 1970s in an effort to help the Chinese-American community in San Francisco care for its elders in community settings. For these families the option of placing frail elderly family members in a nursing home was not a culturally acceptable solution. To meet this community need, On Lok Senior Services ("On Lok" is Cantonese for "peaceful happy abode") created an innovative way to offer a comprehensive array of medical supervision, physical and occupational therapies, nutrition, transportation, respite care, socialization and other needed services.

"One key to the success of PACE is that it emphasizes continuous assessment and aggressive prevention strategies that are free to be employed in the best interest of the individual, without the restrictions of fee-for-service reimbursement," says Shawn Bloom, executive director of the National PACE Association. "By combining flat capitated payments from Medicare, Medicaid and, to a limited extent, private-pay sources, the PACE model delivers services in a manner that would not otherwise even be imaginable and does so in a way consistent with consumer preferences."

"The key to making PACE work financially is keeping hospitalizations and nursing home admittance to a minimum by making sure people get the preventive and primary care they need to stay as healthy as possible," says Judy Baskins, vice-president of Geriatric Services at Palmetto Richland Memorial Hospital, the PACE program in Columbia, South Carolina, "which is exactly what the client also wants. That, in a nutshell, is the beauty of PACE."

To qualify for the PACE benefit, a person must be 55 years of age or older, live in a PACE service area and be certified by the state to need nursing-home-level care. The typical PACE participant is indeed very similar to the average nursing home resident. On average, she is 80 years old, has 7.9 medical conditions and is limited in approximately three activities of daily living (ADLs). Forty-nine percent of PACE participants have been diagnosed with dementia. Nevertheless, PACE has demonstrated that it can successfully provide care that allows extremely frail elders to continue living in the community. Despite their high level of care needs, research has shown that more than 90% of PACE participants are able to do so.