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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2939_Библиотеки_им_академика_М_И_Перельмана
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PACE
VernaSellers andLauraTrice
Introduction
Effective and value-based healthcare for older people is becoming increasingly
important as the number of older adults who require high quality long-term care for
chronic illness continues to increase. How can healthcare providers best serve the
needs of those who are both frail and elderly? Models of care must incorporate cost
containment without compromising participants’ quality of care or quality of life.
Though frail elders say they want to remain at home in their community, frequently,
complex medical conditions and lack of nancial and community resources may
make nursing home placement the only option [1].
PACE is a unique healthcare delivery system that strives to successfully integrate
a full spectrum of services for frail persons 55years of age and older. PACE organizations deliver a combination of primary, specialist, acute, long-term, and homebased care as well as palliative care to its enrollees. Use of interdisciplinary team
care, managed care services, and care coordination result in improved health outcomes and reduced expense over time.
The average PACE enrollee is 77years old, has an average of eight acute and
chronic medical conditions, and three limitations in activities of daily living (ADLs).
Over 95% of PACE participants continue to live in the community [2]. Comparing
this to the data for older adults living in Assisted Living Facilities, who require
assistance with two or more ADLs and average three chronic medical conditions,
the PACE member population is frailer.
V. Sellers (*)
Madison Heights, VA, USA
L. Trice
St. Elizabeth Healthcare, Edgewood, KY, USA
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
P. Winn et al. (eds.), Post-Acute and Long-Term Care Medicine, Current Clinical
Practice, https://doi.org/10.1007/978-3-031-28628-5_4
61
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V. Sellers and L. Trice
Pace History
Program of All-inclusive Care for the Elderly (PACE) originated in 1971in San
Francisco’s Chinatown, with a $2000 federal grant to the Chinatown-North Beach
Health Care Planning and Development Corporation (later renamed On Lok
Senior Health Services). Marie-Louise Ansak, a Swiss social worker, developed a
long- term care model for an elderly Chinese population that considered nursing
home placement culturally unacceptable. Ansak developed the concept for the
original PACE site out of the British Day Hospital’s model, which offered therapeutic and minor medical services, with patients returning home at the end of the
day. The American version, “On Lok” (Cantonese for peaceful abode) expanded
these provisions, thereby creating a global approach to managing patient cases,
which included offering housing, a full range of medical and social services, and
therapies.
On Lok continued to succeed and grow in the 1970s, and by the 1980s On Loc
had received waivers from Medicare and Medicaid to pilot a new nancing
system that allowed the PACE programs to provide full medical services for a
xed monthly payment for each enrollee in the program [3]. In 1986, federal
legislation allowed for other PACE sites and in 1997, PACE received perma-
nent Medicare and Medicaid provider status under the Balanced Budget Act.
Alexian Brothers Community Services in St. Louis became the rst PACE site
to become a permanently recognized part of the Medicare and Medicaid pro-
grams. When the Federal Interim Regulation for PACE was published in 1999
there were 30 programs in 19 states. PACE organizations became subject to
both Federal and State regulation and surveys in a manner similar to those of
long-term care facilities.
PACE expansion to rural markets was initiated by a 2005 Decit Reduction Act
with $7.5 million in funding. There are currently over 137 PACE programs in 31
states with more than 53,000 enrollees.
The National PACE Association (NPA) was founded in 1994 to support PACE
programs. NPA provides education resources, communication forums, and collects
benchmarking data to compare participant characteristics and service delivery
across sites. NPA works closely with members of Congress, senior administration
ofcials, and state policy-makers to educate and to promote a reimbursement and
regulatory environment that enables PACE programs to provide high-quality, individualized, and innovative care. The NPA Primary Care Committee develops
resources to assist PACE clinicians, serves as a clinical resource to the NPA Board
of Directors, and promotes PACE to the wider medical community.
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Financing
PACE offers an innovative nancing model that integrates capitated Medicare and
Medicaid dollars per enrollee. Once enrolled, PACE becomes the participant’s
sole source of Medicare- and Medicaid-covered services, including coverage of
medications. Most PACE participants are dually eligible, i.e., have both Medicare
and Medicaid, but do have the option to pay privately if they do not. Medicare
rates are calculated for each participant using a risk-adjusted payment methodology similar to Medicare Advantage plans. Medicaid rates are negotiated between
each PACE organization and the state agency administering the Medicaid program. PACE organizations assume all nancial risk for delivering all healthcare
services that would normally be covered under Medicare Parts A, B, D and
Medicaid. PACE programs are considered Medicare Advantage Programs and are
funded under Medicare Part C.PACE is in a unique position as both payor and
provider of services that allows for payment exibility, creativity, and innovation.
In 2015 the US Secretary of the Department of Health and Human Services authorized for-prot entities to also operate PACE with the goal of reaching more people. This is contingent on their ability to demonstrate that they can provide care
that is similar to nonprot PACE with regard to access to care, quality of care, and
cost-effectiveness [4].
Outcomes
Although there are limited outcome studies on PACE, the results are generally
positive: PACE has been shown to improve functional status and quality of life,
and decrease mortality [5–7]. Findings also suggest that the very old
(80–90years), those living alone, using ambulation aids, cognitively impaired,
and requiring assistance to perform instrumental activities of daily living
(IADLs) benet the most from a noninstitutional long-term care approach such
as PACE [8].
Rates of hospitalization, readmission, and potentially avoidable hospitalization (PAH) are lower for PACE enrollees than for comparable Medicaid nursing
home residents [7, 9, 10–12]. The variation in study results across PACE sites
reects their heterogeneity in case mix, longevity, and experience of the interdisciplinary team (IDT). The programs availability of transitional housing, contracts, and agreements with local hospitals and skilled nursing facilities, as well
as the local medical culture also caused the programs results to vary [7, 11 12].
In the PACE community an adage frequently used to describe the diversity of the
programs is, “if you have seen one PACE program, you have seen one PACE
program.”
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V. Sellers and L. Trice
A Day at thePACE Day Health Center (DHC)
The IDT
• Primary care provider (may be a Physician or Physician Assistant or Nurse
Practitioner as dened by state laws with regard to oversight, practice authority,
and prescriptive authority)
• Registered nurse
• Master’s-level social worker
• Physical therapist
• Occupational therapist
• Recreational therapist or activities coordinator
• Dietician
• PACE center manager
• Home care coordinator
• Personal care attendant or his or her representative
• Driver or his or her representative
Case Scenario
Like other PACE enrollees, Anna enjoys attending the DHC an average of three
times a week. Her home health aide (HHA) arrives at Anna’s home early to prepare
Anna for the day. Anna’s daughter welcomes the aide into their small apartment.
Anna depends on PACE HHAs for her daily personal care since a stroke left her
wheelchair bound. Bathed and dressed, Anna waits in the living room for the
PACE driver to pick her up for the trip to the DHC.Meanwhile in the kitchen, her
daughter shares a list of concerns with the aide, which include nancial and medical, as well as equipment and supply issues for her mother. The aide assures her
daughter that everything will be addressed at the IDT meeting later in the morning.
Her driver arrives to transport Anna to the DHC.A PACE driver for many years,
he is very familiar with all the people on his route and Anna greets him like an
old friend.
When Anna enters the DHC, the staff greets her, while giving her a nametag.
Her arrival time is entered into the electronic medical record, alerting clinical
staff that plans to see her during the day. The DHC serves as the main medical
center as well as the social services base for PACE participants. There is a full
schedule of recreational activities that Anna may attend but she rst heads for the
therapy department. She had completed skilled therapy after a stroke 2years ago,
but like many PACE participants, benets from an ongoing restorative therapy
program.
Meanwhile, Anna’s IDT is meeting in a conference room nearby. The IDT is
responsible for the initial assessment, periodic reassessment, plan of care, and coordination of 24 h care delivery as written in the Code of Federal Regulation (42
CFR:460.104). Medical care is coordinated by the PACE IDT assigned to each participant. The IDT’s members include physicians, nurse practitioners, behavioral
health specialists, nurses, social workers, therapists, van drivers, aides, and other
staff. This group meets regularly as the status of a PACE participant evolves.
PAC E
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The HHA has reported Anna’s daughter’s concerns to the home care coordinator,
to be discussed at the IDT meeting. Problems with increased knee pain, questions
about a new medication, issues with a defective wheelchair and difculties paying
the rent are all discussed. Agreeing to a plan, IDT members will address these issues
and concerns in the next few days.
Anna then arrives at the PACE clinic for an acute visit with her PACE primary
care provider (PCP) who routinely sees Anna every 3months alternating between
reassessment and wellness visits. Because the clinic is physically part of the DHC,
acute visits are exible and frequent. Frontline staff, HHAs, and drivers are often
the “eyes and ears” of a PACE program, often identifying changes in condition well
ahead of clinic staff. The PCP was informed about Anna’s new onset of left knee
pain during the IDT meeting, that her daughter has noticed a decrease in her mobility and that the therapy staff also noticed decreased range of motion during the
morning restorative exercises. After ordering conservative treatment measures, the
physician reassures Anna she’ll see her again on a subsequent DHC visit.
Working at a PACE is a “dream job” for the PCP.With a small patient panel, typically 100 or less, there is the opportunity to manage complex social and medical
conditions of each enrollee and to see positive outcomes.
Anna’s nurse, telephones to update her daughter, reassures her that her mother’s
vital signs and weight are stable, answers questions about any new medication, and
explains the plan of care for her mother’s knee condition. Her occupational therapist
has ordered a new part to x her wheelchair and the social worker will schedule a
meeting with her landlord.
During the next month at the DHC, Anna has the opportunity to see several
PACE in-house specialists from podiatry, optometry, dentistry, and behavioral
health.* (In-house services vary from center to center.) PACE also schedules and
provides transportation for any other specialist appointments approved by the
IDT. Several times a year PACE admits Anna to a contracted nursing home for
respite allowing her daughter to visit family in another state. Should Anna ever need
a hospital or skilled nursing facility (SNF) stay, PACE clinical staff will continue to
follow her at the SNF with the IDT authorizing and overseeing all care.
In the late afternoon, Anna leaves the DHC for her trip home. The driver will
deliver all her medications, frozen meals, and incontinence products when he drops
her off. Anna knows there is a PACE nurse and provider on call 24/7 should any
issues arise at home during the night or on the weekends.
Tired but happy, Anna is already looking forward to her next DHC visit!
In 2020 PACE programs throughout the country were faced with the COVID-19
pandemic. PACE programs showed success 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, while facing many challenges that
required major changes in care provision. Administrators in a North Carolina study
felt that, after the pandemic, the PACE service model is likely to remain more homebased 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 [13].
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V. Sellers and L. Trice
PACE Model Practice
Beginning in 2006, the NPA Primary Care Committee began developing Model
Practices as guides for key chronic conditions often seen in PACE participants.
These model practices direct care along one of three pathways according to the
directives and priorities of each participant: achieving longevity, maintaining func-
tion, or receiving palliative care [14]. Current Model Practices include the following:
• Atrial Fibrillation (2018)
• Diabetes Mellitus (revised 2014)
• Dementia (2014)
• Coronary Artery Disease (2020)
• Chronic Heart Failure (revised 2018)
• Chronic Kidney Disease (revised 2016)
• Chronic Obstructive Pulmonary Disease (2013)
• Preventive Care Guideline (2010)
NPA encourages the use of these model practices. NPA members may obtain the
documents at Members Only/Primary Care Resources/Model Practices. Nonmember
clinicians or organizations may not use, reproduce, or modify the model practices
without the expressed written consent of the National PACE Association. To obtain
permission, inquire at email info@npaonline.org.
Role oftheMedical Director inPACE
My inspiration and continued passion for geriatric healthcare are a direct result of
a most challenging but rewarding position I held as a PACE Medical Director.
42CFR:460.60 The organization must employ a medical director who is
responsible for the delivery of participant care, for clinical outcomes, and for the
implementation, as well as oversight, of the quality assessment, and performance
program.
A PACE Medical Director operates as both a director of diverse clinical services
and an administrator of a health plan. The need to move from a provider to a payor
role during the work day can be very challenging that includes reviewing and enrollees’ charts and nancial reports. Medical Directors who come to PACE with a longterm care background usually have a good understanding of federal and state
regulatory compliance while those with a primary care practice background often
better understand stafng and balance sheet issues.
Medical Directors must assure that participants receive quality geriatric care in
every setting including the PACE clinic, hospital, SNF, and home. Since PACE providers often provide all these direct services, the Medical Director has the opportunity to closely supervise all the clinical care the participants receive while monitoring
the quality of contracted provider services. While clinical responsibilities are key,
PAC E
67
the Medical Director must also work closely with the Site manager and other administrative staff to manage the nancial risk of the program and plan for expansion of
the program.
Although PACE sites endeavor to recruit geriatricians for both the Medical
Director and Primary Care Physician (PCP) roles, there is not always a supply to
meet the need. Finding practitioners that have a passion for elderly care is always the
priority. The typical PACE program is small, with an average of 300 participants; so
many Medical Directors also function as the PCP in addition to their administrative
duties. Recruiting, training, and retaining PCPs are key responsibilities. The PACE
PCP must be able to care for medically complex elderly using sound geriatric medicine principles. Working collaboratively as an IDT member is often a new experience for a PACE PCP and usually requires 6months to become procient in the role.
Many PACE sites also successfully use nonphysician providers such as nurse practitioners and physician assistants to serve as PCP and be a member of the IDT.
The Medical Director must also recruit and contract with a provider network that
include specialists, hospitals, SNFs, pharmacy, and all ancillary services such as
home care and durable medical equipment suppliers. While the program director
will oversee and maintain contracts with each network member, the Medical Director
must ensure that the network is educated about PACE and provides quality care.
Oversight of the Quality Assessment and Performance Improvement (QAPI)
plan includes making sure that utilization of services, caregiver and participant satisfaction, safety, and clinical outcome measures are addressed. Similar to the functions of a nursing home quality committee, wound care, infections, and falls are
routinely reviewed. Additional QAPI responsibilities include oversight of staff
competency and tracking participant grievances.
There is great opportunity for the Medical Director to educate, mentor, and participate in research. PACE sites often become centers of geriatric excellence for
sponsoring healthcare organization, with fellows, residents, medical students, and
nursing students routinely rotating with PACE clinical staff.
The Primary Care Committee of the National PACE Association (NPA) provides
excellent training resources for all Medical Directors regardless of experience level
or background. Education sessions are offered during the summer and fall. NPA
conferences and online resources are available for NPA member Medical Directors
on the NPA website.
PACE intheNursing Home
Although the goal of PACE is to care for nursing home eligible people in the community, about 10% of PACE participants require skilled or custodial nursing care.
Like all other contracted services, PACE sites must ensure that contracted nursing
facilities are educated about PACE and provide quality care. Ideally, PACE sites
contract with an adequate number of nursing homes to be able to offer enough geographic choice to meet participant and family preferences. PACE and nursing
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V. Sellers and L. Trice
facility administrative and clinical teams need to collaborate to ensure that documentation and care plans are integrated. It is helpful to attend the Quality Assurance
meetings at all contracted nursing facilities, as well as communicating frequently
with the facility administrator, medical director, and director of nursing. CMS
requires a comprehensive medical record at the PACE site even if the participant
resides in a nursing facility.
The Future ofPACE
Operational challenges have limited growth for PACE despite its attractive features
[15]. Signicant human and nancial resources are required to run what is essentially a small health plan. Substantial “back-ofce” overhead costs to process Part A
and B claims as well as Part D data requirements and federal and state reporting
requirements mean less dollars for patient care [16]. Hiring qualied staff especially
primary care physicians and geriatricians can be challenging.
Expanding PACE organizations is often limited by federal regulation that has not
kept up with modern innovations [17]. NPA is working with Congress to support
more operational exibility, growth, and innovation. Issues to explore and address
include expansion of service areas, revision of the age and HF eligibility requirement, utilization of alternative care settings, and unbundling of services.
Pearls for the Practitioner
• Nursing home eligible participants that are age 55 or older can continue living in
their homes with comprehensive services through PACE.
• PACE is a unique model that delivers a full continuum of care.
• With capitated Medicare and Medicaid payments, PACE serves as a model for
value-based care and payment innovation.
Websites
• National PACE Association. www.npaonline.org.
• Medicare.gov. http://www.medicare.gov/your- medicare- costs/help- paying-
costs/pace/pace.html.
• Medicaid.gov. http://www.medicaid.gov/Medicaid- CHIP- Program- Information/
By- Topics/Long- Term- Services- and- Supports/Integrating- Care/Program- of-
All- Inclusive- Care- for- the- Elderly- PACE/Program- of- All- Inclusive- Care- for-
the- Elderly- PACE.html.
References
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2006:90–2.
2. National PACE Association. www.npaonline.org.
PAC E
3. Eng C, Pedulla J, Eleazer GP, McCann R, Fox N.Program of All-inclusive care for the Elderly
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4. Gonzalez L.A focus on the Program of All-Inclusive Care of the Elderly (PACE). J Aging Soc
Policy. 2017;29(5):475–90.
5. White AJ, Abel Y, Kidder D.Evaluation of the program of all-inclusive care for the elderly
(PACE) demonstration. A comparison of the PACE capitation rates to projected costs in the
rst year of enrollment. Baltimore: Abt Associates; 2000.
6. Mancuso D, Yamashiro G, Filver B.PACE an evaluation. Olympia: Department of Social and
Health Services, Research and Data Analysis Division; 2005.
7. Weiland D, Boland R, Baskins J, Kinosian B. Five year survival in PACE compared with
alternative institutional and home and community based care. J Gerontol A Biol Sci Med Sci.
2010;65(7):721–6.
8. Branch LG, Coulam RF, Zimmerman YA.The PACE evaluation: initial ndings. Gerontologist.
1995;35:349–59.
9. Chatterji P, Burstein NR, Kidder D, White AJ.Evaluations of the Program of All-Inclusive
Care for the Elderly (PACE)—demonstration the impact of PACE on participant outcomes.
Boston: Abt Associates; 2003.
10. Meret-Hanke LA.Effects of the Program of All-Inclusive Care of the Elderly on hospital use.
Gerontologist. 2011;51:774–85.
11. Beauchamp J, Cheh V, Schmitz R, Kemper R, Hall J.The effects of the program of all- inclusive
care for the elderly (PACE) on quality. Princeton: Mathematica Policy Research; 2008.
12. Segelman M, Szydlowski J, Kinosian B, Mcnabney M, etal. Hospitalization in the Program of
All-Inclusive Care for the Elderly. J Am Geriatric Soc. 2014;62:320–4.
13. Schamp RO.A day in the life of a PACE medical director. Caring for the Ages. 2011;
14. Aggarwal N, Sloane PD, Zimmerman S, Ward K, Horsford C.Impact of Covid-19 on structure
and function of Program of All-Inclusive Care for the Elderly sites in North Carolina. J Am
Med Dir Assoc. 2022;23:1109–13.
15. Boult C, Wieland DG.Comprehensive primary care for older patients with multiple chronic
conditions “Nobody Rushes You Through”. J Am Med Assoc. 2010;304:1936–43.
16. Hirth V, Baskins J, Dever-Bumba M.Program of All-Inclusive Care (PACE): past, present, and
future. J Am Med Dir Assoc. 2009;10:155–60.
17. Bloom S.PACE has shown path to improved elder care. Modern Healthcare. 2014.
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Department ofVeterans Affairs Options
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forLong-Term Care
DeborahWay
Introduction
The Department of Veterans Affairs (VA) has developed several options for longterm care from traditional institutional care to innovative programs for communitybased long-term and post-acute care. Similar to the triple aims of the Centers for
Medicare and Medicaid Services, the VA is focused on providing cost-effective care
using community-based services aimed at reducing hospitalizations and preventing
institutionalization. These VA services include Hospital in Home, Home-Based
Primary Care, Clinical Video Telehealth (CVT), Telehealth, and Homemaker Home
Health Aide Care. End-of-life care including hospice may be available to Veterans
based on clinical need. Also, Veterans may receive nursing facility (NF) care based
on military service-connected status, level of disability, and income requirements.
This would be available either at an inpatient VA facility called a Community Living
Center (CLC) or at a VA contracted nursing facility.
D. Way (*)
Palliative Care Services, Corporal Michael J.Crescenz VA Medical Center,
Philadelphia, PA, USA
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
P. Winn et al. (eds.), Post-Acute and Long-Term Care Medicine, Current Clinical
Practice, https://doi.org/10.1007/978-3-031-28628-5_5
71
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