PACE Programs Continue to Innovate

Massachusetts-based Element Care extends PACE day-care programs into the home.

Healthcare Innovation

The pandemic’s devastating impact on nursing home residents also put a spotlight on programs that care for patients with complex care needs in the community. Many of them have had to get creative and rely on technology to find new ways to care for their patients.

Program of All-Inclusive Care for the Elderly (PACE) is an evidence-based model of care for older adults who meet a nursing-home level of care but mostly live in community settings. There are approximately 260 PACE organizations in 31 states serving nearly 54,000 individuals. On average, each one works with about 400 enrollees. They are a high-cost, high-need population with significant impairments. On average, enrollees have six chronic conditions and 46 percent have dementia. Ninety percent are dually eligible for Medicare and Medicaid. PACE organizations receive capitated payments and are responsible for all services, including medical, behavioral, and long-term care services and support. Teams have flexibility in funding and can address social determinants or use funding to provide services such as installing an air conditioner for a person with respiratory illness.

While all PACE participants must be certified to need nursing home care to enroll in PACE, only about 7 percent of PACE participants nationally reside in a nursing home. If a PACE enrollee needs nursing home care, the PACE program pays for it and continues to coordinate the enrollee’s care. When the pandemic hit, these programs took innovative steps to shift many of their services from PACE day centers to home settings.

Founded in 1994, nonprofit Element Care was established as a joint venture of the Lynn Community Health Center and Greater Lynn Senior Services to bring the Program for All Inclusive Care for the Elderly to seniors in their Massachusetts community. Today, Element Care has eight PACE Adult Day Health Centers and two alternate care settings covering the North Shore, Merrimack Valley and the Northeast region of Middlesex County.

Joanna Duby, M.D., medical director for Element Care, said each center has about anywhere from 120 to 200 older adults affiliated with it. “Typically, we have a day center there. People come in during the day, they get some breakfast, they get some lunch, we have activities, and they also get their medical care. We have nursing staff, physical therapy staff, social workers, nutritionists, and doctors, nurse practitioners, and our own behavioral health staff. We’re a very flexible model. If somebody needs to be seen at home, they get seen at home.”

All that changed when the pandemic hit and the older adults in the program could not congregate. Previously, Element Care hadn’t paid much attention to telehealth because they didn’t think it fit with their population’s needs and capabilities, Duby said. “Once the pandemic struck, we took another look at telehealth visits to see if they could be friendly to our elders, because we didn’t know how long this was going to last.”

They eventually partnered with a company called GrandPad, which has its own proprietary tablet device aimed at older adults. “It’s a very simple interface. There are very limited things they can do on them,” Duby explained. Users can only be called by people who are on their list. With the press of a button, they can reach a nurse. “We rapidly deployed those and the behavioral health team started using it, the physical therapy team started using it either for individual therapy sessions or for even group sessions,” Duby added.

Gradually, the PACE participants also used it for activities that they were missing. They had coffee hours with other friends from the center that they hadn’t seen in a year. “We also did nurse and/or nutritionist visits. Within six months we had between 300 and 400 users on them, and I don’t see them going away,” Duby said. “I think the people who have them like them and want to keep using them. They can do video chats with their families and friends. As a program, we’ve always appreciated how someone’s home life and not being lonely and being connected was just as important as the meds they take, what they eat, and making sure they had something to eat and a roof over their head.”

Element Care is gradually opening up its centers again, but it is going to continue to do  video calls with the people who have GrandPads so clinicians can see how how they’re doing on a regular basis.

“We’ll continue to evolve and learn,” Duby said. “I think we will absolutely continue to use these and learn from it and improve on it.”

During a webinar presentation during the height of the pandemic, consultant Anne Tumlinson said, “The implications of what we have been able to observe PACE organizations doing during the pandemic with their care model, with their teams, with their resources, is that we have learned that provider-led risk models must be fostered going forward. That includes PACE, but is broader than PACE.”

Tumlinson added that states and the federal government have a mandate to think strategically about how to broaden the reach of PACE. “And PACE organizations have to think more strategically about how they are going to broaden the portfolio of solutions they offer and the price points at which they offer them. They have to organize their services and interventions within different types of risk-based products that Medicare and Medicaid offer. For state and federal government policymakers, the notion that we have this money available to people for room and board only in a nursing home, that time is over.”

The imperative, she added, is for flexibility to deploy healthcare dollars differently. “We can’t do that through fee for service. There is nobody managing that pot of dollars and they are not flexible. We have to keep people at home, address engagement and reduce isolation and meet medical needs remotely. We are going to have to do that for a long time. That is going to be our mandate for the foreseeable future for this population. By definition, we have to be able to evaluate needs, access resources on their behalf, manage a complex array of services and coordinate it — all of that can only be done in a really flexible platform like PACE.”


How COVID-19 Exposed the Faults in America’s Elder Care System. This Is Our Best Shot to Fix Them

JUNE 15, 2021 7:00 AM EDT
TIME Magazine
For the American public, one of the first signs of the COVID-19 pandemic to come was a tragedy at a nursing home near Seattle. On Feb. 29, 2020, officials from the U.S. Centers for Disease Control and Prevention (CDC) and Washington State announced the U.S. had its first outbreak of the novel coronavirus. Three people in the area had tested positive the day before; two of them were associated with Life Care Center of Kirkland, and officials expected more to follow soon. When asked what steps the nursing home could take to control the spread, Dr. Jeff Duchin, health officer for Seattle and King County, said he was working with the CDC to provide guidance, “but,” he acknowledged, “it is a very challenging environment, particularly with so many vulnerable patients, to manage an outbreak.”

It turned out the virus had already been circulating among Life Care’s residents for weeks by the time administrators took action, and soon it was tearing through the facility. By March 5, at least nine residents had already died of COVID-19, and a group of families whose loved ones were still inside held a desperate press conference. “Our families are dying. We don’t know what to do. Our calls for help aren’t working,” Kevin Connolly, whose father-in-law lived in the facility, told reporters. “We have limited resources to battle this disease, and I think somebody somewhere decided that this population of people wasn’t worth wasting resources on.”

Many long-term-care experts would say Connolly was right. The pace at which that first U.S. coronavirus outbreak spread through Life Care, killing dozens of residents in weeks, shocked the public. But for those familiar with long-term care, it wasn’t surprising. “We really failed in a lot of ways, historically but also during this pandemic, to value older adults,” says David Grabowski, a professor at Harvard Medical School and an expert on long-term care. That is to say, the U.S. health care system basically left its nursing-home residents as sitting ducks for a viral pandemic like COVID-19.

Nursing homes and other group facilities are inherently petri dishes for pathogens. People with frail health frequently share rooms and rely on workers to help them bathe, eat and get out of bed. The staff perform physically and emotionally taxing work for little pay and few benefits, which means they often work for multiple facilities to make ends meet, potentially spreading infections further, as the CDC found was the case with Life Care.

Even before the pandemic began, the low pay and tough working conditions had led to high turnover among U.S. nursing-home workers, and facilities struggled with infection control.

This wasn’t the case around the world. Many wealthy countries have smaller group homes with more private spaces and highly trained care workers, and generally spend more on their elders. In Denmark, for example, which spends 2.5% of its GDP on a universal long-term-care system compared with the U.S.’s 0.8%, deinstitutionalizing care has been prioritized. Even when Danes do live in nursing homes, they often have individual apartments—perhaps one reason that by February 2021, the country had recorded fewer than 950 deaths among nursing-home residents, while in the U.S., as of mid-May, more than 132,000 long-term-care facility residents had died from COVID-19, accounting for nearly 25% of the country’s total coronavirus fatalities. This horrific toll sent the nursing-home industry into free fall, with occupancy rates plummeting 14% from first quarter 2020 to first quarter 2021 as new admissions dropped, according to the National Investment Center for Seniors Housing & Care research group.

The nursing-home industry says that it has lost tens of billions of dollars during the pandemic and that many facilities are in danger of closing. COVID-19 vaccines have improved things, but images of last year’s destruction may not fade quickly for people who need care or for their families. The pandemic has thrown into relief concerns that advocates, experts, workers, industry reps and patients have long raised about long-term-care facilities, and it has created a unique moment, they say, to reconsider how the country can better care for people outside those settings in the future.

“What we collectively realized [during the pandemic] is that we’re all isolated and dealing with the same struggles because of a lack of care infrastructure in this country to support our ability to take care of the people that we love, particularly as we’re working,” says Ai-jen Poo, co-director of Caring Across Generations, which advocates to strengthen the long-term care system. “It’s really a once-in-a-lifetime opportunity to update our public policy, our systems and our infrastructure for the next era.”

Ideally, all older adults and people with disabilities would be able to choose their care based on what they, along with family members or case managers, believe is most appropriate—and not on cost. Yet, unlike most other rich countries, the U.S. does not provide a public long-term-care benefit for everyone who needs it. The result is a system that is fragmented. Care is often siloed into two categories, medical treatments and social/personal support; under-financed; and frequently leaves people with little choice about their care. Many end up in group homes when there is no clinical reason for them to be there, and those who do stay at home often struggle to find or afford enough professional care to meet their needs, instead relying on unpaid family caregivers.

One of the biggest challenges is paying for care. Medicare, the federal program that provides health insurance for seniors, does not cover most long-term services. Instead, Medicaid, the federal-state program that covers the health care of very low-income Americans, ends up being the primary payer for long-term care. But in most states, older adults must have a monthly income under $2,382 and $2,000 or less in assets to qualify. That leaves many middle-income Americans with too much money for Medicaid but unable to afford expensive care. Roughly 8 million seniors fall into this category, a number expected to reach 14.4 million by 2029, according to a Health Affairs study co-authored by Grabowski.

Thompson can now cook meals in her kitchen without falling or becoming too tired to eat.

In addition, Medicaid has a historical structural bias toward institutions. While Medicaid is required to cover care in group facilities (for those who do qualify), there’s no coverage mandate for care delivered in people’s individual homes. States have started to shift their Medicaid spending toward home- and community-based services over the past decade, but the amount and type of home care available still varies widely by state.

Further, states can cap Medicaid enrollment, creating long waiting lists for home-based care. There were 820,000 Americans on such lists in 2018, the most recent year for which data is available, according to the nonpartisan Kaiser Family Foundation. The average wait time is 39 months, and many people see their health deteriorate or die before they get help, says Nicole Jorwic, senior director of public policy for the Arc, a nonprofit that supports people with disabilities.

That long wait is in part due to a scarcity of home health aides and nurses in the U.S., a trend further exacerbated by the pandemic. Dottie Walden, 74, saw the shortage firsthand this year when she tried to find help in rural Georgia while caring for her husband Joe, who had a stroke in 2015 and a feeding tube inserted last winter right before the pandemic began in earnest. For the past year, she’s spent every day bathing, feeding and moving him around their home—even when lifting him caused her to pull her own back. When Dottie started looking for help this spring after she realized she could no longer move him safely, it took a local care coordinator contacting three home-care agencies and waiting more than four weeks to find a company that had enough staff to cover Joe’s needs. “It’s so dangerous for me to even go out here to the grocery store for a few minutes and leave him. You walk out the door, and you don’t know when you come back in what you’re going to find,” Dottie says. “You’re thinking every night, Maybe tomorrow will be the day that I will have some help. It just really takes a toll on you.”

The financing issues that make it tough for families to afford care also constrain what care workers can make, as Medicaid pays rates the industry has long complained are too low. Home-care workers earn a median hourly wage of $12.60, according to the Bureau of Labor Statistics. More than 15% live in poverty, and more than half rely on some form of public assistance like food stamps, according to the Paraprofessional Healthcare Institute (PHI), a nonprofit that advocates for long-term-care jobs. Tracey Richards has been a home-care worker in Las Vegas for over 15 years, making $9 to $10 an hour for most of that time. This March, she switched agencies and now makes $13 per hour. Even with the raise, Richards can’t afford health care for herself, let alone save for the future. “I cry about it at night,” she says. Richards says she knows her work is essential and she deserves to be paid a wage that reflects it—she also knows she could make more money doing another job, but she doesn’t want to leave the clients who rely on her. “They don’t have anyone else,” she says.

Most home-care workers look like Richards: 9 in 10 are women, and nearly two-thirds are people of color. They’ve been trying to advocate for better pay and working conditions for years, but long-standing racism and sexism has led the country to undervalue this work and made change slow, says April Verrett, president of SEIU Local 2015 in California, the country’s largest union of long-term-care workers.

These efforts may soon get a lift. President Joe Biden has proposed spending $400 billion over eight years on home care for the elderly and people with disabilities as part of the infrastructure plan he hopes Congress will pass this summer. While that isn’t enough to fix all the problems with long-term care—and it’s not clear whether the funding will make it through negotiations with Republicans—it would be the biggest investment in this kind of care in more than half a century.

The CAPABLE program provides $1600 for a handy worker, home modifications and assistive devices.

Biden’s economic stimulus passed in March included a one-year investment of $12.7 billion for these kinds of home-and community-based services, but Jorwic sees that as “filling holes in a sinking ship” after the stress the pandemic put on care providers. She’s heard from states that are wary of using that funding to make significant changes to their home-care programs because the money runs out after a year. Even beginning to permanently improve home care, she says, will require the kind of funding Biden has proposed in his infrastructure plan.

The problems with long-term care are only getting more urgent. Some 10,000 Americans turn 65 every day, and the Census Bureau projects the number of seniors will reach 94.6 million by 2060, with the majority expected to need long-term-care services at some point. Retirement savings have not kept up with lengthening life expectancies. After a year and a half of a pandemic that drove millions of women out of the workforce, advocates are also making the case that addressing the simmering care crisis is key to the nation’s economic recovery.

As lawmakers look to change the country’s long-term-care system, advocates and researchers are exploring creative solutions to tackle not only the issues of access to care and worker pay, but also the kinds of care Americans receive in their homes. Right now, Medicare and Medicaid each pay only for specific services, and individuals must navigate complex systems to find support, which means their doctors don’t always talk to other care-givers, and medical care is often siloed from other social and personal support someone might need. A better system might align all these services under one payer, says Rachel Werner, a professor of medicine at the University of Pennsylvania, so that providers are incentivized to help manage all parts of their patients’ care and could keep them in their own homes, which is typically the least expensive setting. One such program is CAPABLE, or Community Aging in Place—Advancing Better Living for Elders, a model developed by researchers at Johns Hopkins University (JHU) that offers low-income seniors regular visits from a nurse, an occupational therapist and a home-repair person over the course of about four months.

Sarah Szanton, a professor at JHU’s School of Nursing, came up with the idea over a decade ago, when she was a nurse practitioner treating homebound patients. She saw clients who had developed coping mechanisms to stay at home—like crawling around the kitchen because their wheelchair wouldn’t fit through the door frame—that were making their lives less enjoyable and more dangerous. While it was important to treat conditions such as diabetes or congestive heart failure, she realized that holistic, often non-medical interventions like teaching someone to shower on their own or finding a new way to reach the second floor of their house were just as important.

The CAPABLE program has grown significantly over the past few years. It now has 33 sites across 18 states, and Szanton and her colleagues have strong evidence the model works. Studies have shown it reduces hospitalizations, depression and the number of functions with which participants report struggling. Federal evaluators found the program saves both Medicare and Medicaid roughly $10,000 per year per participant. And because it can help some people function more independently in their own homes for years or even avoid a nursing home permanently, Szanton believes it could stretch the country’s current supply of care workers.

Nancy Thompson checks her mail using equipment from the CAPABLE program.

For 72-year-old Nancy Thompson, CAPABLE has changed her whole life. Until last year, Thompson had a grim routine. At least once a month she would fall down—maybe while making dinner or perhaps when getting out of the bathtub. Next there would be a trip to the emergency room, followed by out-patient wound care and sometimes months of home health care, depending on the severity of the fall. She thought about getting a knee replacement, which would in theory improve her balance, but before she could follow through, she fell again and needed to heal before her doctor would approve it. The cycle was always expensive—and Hurricane Harvey devastated her savings a few years ago—but Thompson felt she had no other options.

Her collapsed foot and weak knee were making it increasingly difficult to walk, and the health care she was getting was depleting what little money she had left, but at least she managed to return to her own condo outside Houston after each accident. “I don’t ever want to end up in a nursing home,” she says. The pandemic heightened that fear, but fortunately, Thompson’s primary care provider, Village Medical at Home, wanted to try CAPABLE for some of its patients. Starting in December, the program’s staff helped Thompson develop personalized goals like climbing in and out of her tub without falling and cooking dinner safely without getting too tired to eat; facilitated long-needed doctor appointments; and paid for necessary assistive devices including a wheelchair, a specialized kitchen stool and a raised toilet seat. All of this was free for Thompson. “I haven’t been to the hospital, to the emergency room or anything since I’ve been with them,” she says. “And for me, that is totally amazing.”

Most CAPABLE sites right now are still relatively small pilot programs funded by grants or individual organizations, but the program is making progress. Massachusetts was recently the first state to get approval for Medicaid to pay for CAPABLE; other states are now exploring this option. Private Medicare plans, also known as Medicare Advantage, can now cover it, and the first Medicare Advantage CAPABLE site is launching in Missouri this summer. The federal Department of Housing and Urban Development recently announced it will make available $30 million for organizations to run a version of CAPABLE. And the House Ways and Means Committee is working on legislation that would allow CAPABLE to be covered under traditional Medicare, which would open up access to the program to millions of older adults.

The doctors behind Village Medical at Home, which runs Thompson’s CAPABLE program, hope the cost savings they’ll accrue when their patients go through CAPABLE will allow them to keep expanding the program. Senior medical director Dr. Thomas Cornwell says the patient outcomes are so positive they may continue even if the savings end up being only enough to break even. “What’s good for the patient is good for the managed care plan. The managed care plan makes more of a profit, the patient has a better quality of life, stays out of the hospital—in theory, it can work for everybody,” says Howard Gleckman, an expert on long-term care at the Urban Institute.

Nancy Thompson's cat keeps her company at home.

Another program that could expand is PACE, or Programs of All-Inclusive Care for the Elderly, which has centers in 30 states. The program, in some ways a supercharged version of CAPABLE, provides comprehensive medical and social services for older adults who need significant nursing care but want to live at home. PACE sites get a payment every month for each patient, mostly from Medicaid and Medicare, and the program uses that revenue to take care of all the participants’ needs, including routine doctor’s visits and meals at the PACE adult day center, home health aides, laundry services—and if needed, specialists or hospital visits.

“The nature of payment provides significant flexibility, as well as really strong incentives for PACE organizations to really proactively monitor and get out in front and address existing and emerging health needs,” says Shawn Bloom, president and CEO of the National PACE Association. During the pandemic, this meant PACE programs shifted some services from their adult day centers to patients’ homes, added telehealth check-ins and made other changes that providers say kept patients safe. While nursing homes nationally had a COVID-19 case rate of close to 60%, the rate among PACE participants was 19% through the end of March. There are regulatory obstacles to expanding PACE, but U.S. Senator Bob Casey, a Pennsylvania Democrat who chairs the Senate Committee on Aging, has introduced legislation to address some of these, and Bloom’s organization has been lobbying to change them as well.

While such national solutions are still a long way off, individual states are pursuing their own ideas. California Governor Gavin Newsom released a “Master Plan for Aging” in January, calling for 1 million new caregiving jobs and new housing specifically for seniors. Other states such as Massachusetts, Colorado, Minnesota and Texas already have published similar plans; still others are working on their own, spurred in part by the destruction their leaders saw during the pandemic.

In addition, a range of municipalities as well as independent researchers are experimenting with everything from planned communities designed to be accessible for older adults to modular nursing homes and even care homes where disabled or older Americans would live side by side with caregivers and share different chores such as childcare and meal prep in a cooperative-style setting.

None of this will be easy. Republicans have rejected Biden’s $400 billion proposal, and the President has spent weeks trying to work out a bipartisan agreement. Even if Democrats do concede to a smaller infrastructure package that does not include the home-care funding, they could try to get it passed in other legislation that they would force through the budget-reconciliation process later this year. But that’s not certain either, and plenty of experts, advocates and lawmakers are nervous that the likelihood of such an investment is diminishing. The stakes are high. “This is our moment to really provide transformative change to how we care for seniors and people with disabilities,” says Casey. “If we don’t get it right in this moment, I’m not sure we’re going to be able to do this for 10, 20 years.”

Thompson now feels more comfortable navigating her home. “I’m very independent,” she says.

After Nancy Thompson stopped falling down thanks to the training and home modifications provided by the CAPABLE program, her doctors decided this March she was finally ready for her long-needed knee replacement. She recovered in a fraction of the time her team expected, and was able to return home after only 10 days of rehab. Once back in her own condo, her mobility and confidence increased rapidly and she stopped needing home health aides sooner than expected too. Now, she’s planning for the future and considering finally getting her foot operated on later this year—something she had put off for more than half a decade.

“This is the best thing that could have happened to me,” she says. “I can be independent but be smart at it.” That independence is what Szanton, the CAPABLE creator, envisioned when she dreamed up the program. And it’s what most Americans say they want throughout their lifetimes. Now the question is if the political will can meet this moment. With reporting by Emily Barone, Tara Law, Madeline Roache and Simmone Shah

TeleHealth is Here to Stay

After a year of change, how will homecare adapt online?
by Hannah Wolfson
Home Care Magazine


In the earliest days of the emerging COVID-19 pandemic—in a news story published on March 16, 2020, to be exact—we reported that homecare companies were facing a new problem: denials of service. Patients and customers were increasingly refusing to let providers into their homes out of fear of infection, and professionals were declining to go out into the field for the same reason.

“Patients are increasingly hesitant to let nurses into their homes for in-person visits,” Synzi CEO Lee Horner said at the time in an interview that ran on

There was an easy solution, however. The past year saw a massive application of telehealth, something homecare had been slowly working toward for decades. Suddenly, virtual visits weren’t just a nice add-on, they were the only way to reach some patients.

That’s been a catalyst for long-term change, says Horner, who has been in the telehealth industry for about a dozen years, at Synzi and elsewhere.

“With COVID-19 hitting us, health care delivery has changed, especially on the post-acute side, forever,” he said in a recent interview. “I think there was a lot of uncertainty about how video and telehealth would be delivered but I think over the last year it’s been proven to be wildly successful.”

Speedy Adoption

It’s rare in health care to be able to pinpoint the adoption of a new practice to a single year, much less to a single week. But according to the Centers for Disease Control and Prevention, telehealth visits took off during the last week of March 2020, jumping 154% compared to the same week in 2019. Those virtual visits were mostly patients seeking care for something other than COVID-19.

That was just the beginning. Telehealth services grew by more than 1,000% in March of 2020 and more than 4,000% in April of that year, according to a study of almost 7 million privately insured people that was published in JAMA Network Open.

However, a recent report from the nonprofit Fair Health found that telehealth usage dipped 16% from January 2021 to Febraury 2021, indicating a possible slowdown in demand for virtual care as vaccinations increase and health practices reopen.

That doesn’t worry Janet Dillione, CEO of Connect America, which recently doubled down on connected health with its purchase of Philips’ Lifeline business.

“I have been in healthcare IT my whole career,” Dillione said. “The past year has done for this pre-hospital virtual care space what the HITECH Act did for electronic medical records.”

“The pendulum has swung,” she continued. “It perhaps won’t stay this far, but it’s not going back.”

On the broader spectrum of health care, Dillione said, much of the systemic change was driven not just by the existence of the coronavirus pandemic but also by the fact that clinicians were suddenly able to be reimbursed for virtual visits in a way they hadn’t before. In-home care providers, however, have been partly or entirely left out of that—and the pandemic-spurred waivers allowing broader use of telehealth will likely expire along with the public health emergency.

There are three main bills in Washington at press time that would permanently remove the paused restrictions that keep most Medicare patients from using telehealth services from their home or outside rural areas; one of them would require rulemaking to establish other originating sites, another would also give the Centers for Medicare & Medicaid Services (CMS) the authority to establish newly eligible sites, such as a community center or clinic.

There’s still an incentive to adopt, however, Horner said, if only to keep up with the competition.

One Case Study

Before the pandemic hit, the seven adult day centers run by Element Care PACE in Massachusetts were full each day with seniors visiting their doctors, nurses, physical therapists and other clinicians or enjoying enrichment activities. Then, in March, it all shut down.

“We closed and we had to pivot very quickly,” said Dr. Joanna Duby, medical director at Element Care PACE, which serves about 1,000 older adults. “Our nurses had to go out even before we had personal protective equipment; we would go do home visits but we would screen people first. We would call people on a daily or weekly basis to see if they were okay or if we needed to go out and see them.”

That wasn’t a sustainable system, so the organization provided tablets designed for senior engagement and used it for connected activities as well as for virtual care. Element Care is currently testing a pilot that connects the tablet to a scale so patients’ weight can be tracked, and they’re looking at other things it might expand to, including measuring blood pressure, oxygen saturation and body temperature.

Right now, about 350 of the group’s clients are using the tablets and spend an average of three hours a day on them.

PACE organizations like Element might provide an example of what telehealth could look like in the future. Because PACE acts as both caregiver and payer, the programs tend to take a holistic view of care management for participants, who are usually dual eligible for Medicaid and Medicare. Rather than going into institutional care, they stay home, visiting a PACE day center to get care from an interdisciplinary team including proactive physical therapy, a dietician and behavioral health. There’s even a driver that takes them to the center if needed.

Duby said they were surprised to discover that appointment compliance—especially in behavioral health—actually increased with the switch to virtual, so they expect to continue with a hybrid model.

It’s an investment, she said, but it’s worth it if keeping better in touch with a member keeps them active and avoids a life-threatening fall, or if someone’s not feeling up to traveling to the center, even with transportation provided.

“We don’t see this going away now that we’ve started it,” Duby said. “We also are using for enrollment purposes to communicate with potential enrollees.”

What Patients Want

As the push for consumers to age in place increases—another trend that’s been catapulted into overdrive by the pandemic—so, too, will connected health care in all its forms. After all, telehealth can include telemedicine (that is, clinician visits performed by video or by phone); remotely monitoring patients’ vital signs, activity levels and medication usage; and personal emergency response systems, which signal when something has gone wrong.

“If you think about some of the trends the pandemic ended up accelerating, a lot of us stayed home and ended up ordering groceries from Amazon or whoever and you could see the status of your order,” said Nick Knowlton, vice president of strategic  initiatives for ResMed. Telehealth encounters were similar—an encounter with a primary care provider via a video app could lead to a prescribed medicine, a then to a notification from a pharmacy app when it’s ready. Going forward, consumers will want the same ease of use for all their care.

Virtual care and remote monitoring can also be a boon to providers, especially as demand for already-scarce skilled caregivers continues to grow. Virtual visits don’t just save the patients time and hassle, they save companies staff travel time and expense and can also protect vulnerable employees from exposure to contagious disease in someone’s home or threats of violence in the field.

“People are going to stay at home, but there aren’t enough caregivers,” Dillione said. “How do you deliver virtual care? How do you provide that 24/7 stewardship in terms of safety?”

Nevertheless, the experts say, it’s best not to approach telehealth as a replacement for in-person care.

“That’s the wrong mindset,” said Dr. Kurt Merkelz, senior vice president and medical officer at Compassus. “Telehealth should be an additive service—and this is the case with all of health care. Say they’re recovering from a hip fracture and we come into their home and they have chronic diseases, then we look at how we deal with their COPD and their cognitive impairment.”

Rather than try to fix everything at once—or entirely virtually—Merkelz said care teams should develop a new, post-acute focused methodology that blends hands-on and telehealth. A home check would be face to face, but a medication reconciliation meeting can be virtual, as can wound review. And then clinicians can send clients reminders or even interactive video tutorials to educate them on their condition.

“This is how we can leverage telehealth,” Merkelz said. “This is where telehealth has such an opportunity, not as a replacement, but as an additive service. That’s what I’m excited about.”

And Duby said providers should remember one important thing even as the technology accelerates, especially when working with an older population.

“There is still some use in picking up the phone,” she said.







At Home Care for the Elderly

To the Editor, New York Times:

Re “Rethinking Nursing Home Care, Even With Vaccines” (news article, May 9):

Families don’t have to decide between caring for aging parents at home with help from hired aides or sending them to live in nursing homes.

Since the 1970s, Medicaid has paid for people 55 and over to receive nursing home-level care outside of nursing homes through a care model known as Program of All-inclusive Care for the Elderly, or PACE. PACE is widely recognized as the gold standard of care for keeping nursing home-eligible seniors healthy and safe in their own homes, while offering comprehensive medical care, social activities, meals and other support at PACE centers, almost always at far lower cost than institutional care.

Inexplicably, however, PACE has never received the support and promotion it deserves from the federal and state agencies that administer Medicaid. As a result, many families remain unaware that such an alternative is even available.

It’s time for policymakers to establish clear plans for reducing the number of seniors who are living in nursing homes unnecessarily and would be better and more safely cared for in their own homes.


LYNN — After a year of relying almost completely on telehealth, the virtual health platform at Element Care PACE in Lynn has expanded to incorporate avatars, personal reminders and a variety of meeting options for elderly patients.

At Element Care — a nonprofit healthcare organization serving seniors living at home — the telehealth options have evolved into a daily tool for behavioral health services, rehabilitation services, care management and nutrition counselling.

Dr. Joanna Duby, who practices at Element Care, said they have managed to contract devices through Grandpad, which incorporate video visits with family and friends to relieve social isolation, virtual meetings of groups like Alcoholics Anonymous (AA), and events including comprehensive healthcare and social services — available in languages such as Spanish, Portuguese, Khmer, Creole, Russian, and Albanian.

“The participants can use this to connect with different types of health care personnel but also with their families,” Duby said. “They can listen to music and connect with other people that they’ve allowed access to the device, so it’s really the whole package. We can give them healthcare through it and they can also have socialization and activities.”

Element Care uses a system called, where participants can make their own avatar —  usually a cartoon dog or cat — that will remind them to take their medication, exercise or walk around, and other daily reminders. Duby also said the participants can tell the avatar when they’re not feeling well and the doctors can then video call them through the avatar.

“People are using them and enjoying them so far. The uptake has been great,” Duby said. “It takes a little bit of getting used to, obviously, and a little bit of training, but at each of our centers we have people that are champions of this and they help the participants use the devices.”

Duby said some participants can have two to three interactive sessions per day, which are available to Grandpad users through Zoom calls. Duby reports that all of the sessions she’s observed seem to be well attended.

Some of the available sessions include bingo, rehabilitation groups, and behavioral health groups.

“They can access a doctor or nurse practitioner and have their health sessions, but they can also do fun group activities so that they’re kept engaged,” Duby said.

The elderly community has been secluded within the last year out of caution related to COVID-19, so Duby said this resource is huge; she says it brings back some kind of social interactions for her elderly patients.

Element Care began distributing the Grandpads late last summer, and Duby said there were more than 300 participants by December.

“A good percentage of our population has them now,” Duby said.

Element Care has continued providing services throughout the pandemic, with nurses making home visits and someone from Element Care calling and checking in with the patients at least every other day.

Last summer, Duby said the rehabilitation department began performing more home visits, and now Element Care sees 10 to 15 people in-person daily at the day centers. Duby said they are slowly bringing people back into the centers as more of the population is getting vaccinated and capacity restrictions are easing.

Although Element Care is returning to some in-person operations, Duby said they plan to continue using the Grandpads because they are “a great way to keep in touch with people.”

“I think we’ll keep a hybrid form when some people come in in-person, but there’s always going to be some stuff through the telehealth devices as well,” Duby said. “Now that we have it, I don’t see us going back.”

PACE Providers Shift Services Toward the Home Amid Nation’s Long-Term Care Overhaul

The COVID-19 pandemic has revealed a dire need to rethink how and where Americans age, most long-term care experts agree.

Investing in small-home senior living and “nursing homes without walls” are among the several innovative ideas that have been floated over the past year. Alternatively, some aging services stakeholders have simply called for a sweeping redirection of government funds away from facilities toward in-home care, something President Joe Biden is backing in his newly proposed “American Jobs Plan.”

There’s another way to reimagine long-term care in the U.S. that isn’t being talked about nearly enough, however: Programs of All-Inclusive Care for Elderly (PACE).

“I think we’re now in a situation across the country, as well as in Massachusetts, where PACE is being recognized as a significantly improved opportunity and alternative for health care delivery,” Dr. Rob Schreiber, vice president and medical director of Fallon Health’s Summit ElderCare, told Home Health Care News. “Specifically for those who are nursing home eligible and want to maintain their lives in the community.”

As of March 30, there were at least 138 PACE organizations operating 272 PACE centers in 30 states, serving roughly 55,000 participants combined, according to the National PACE Association.

Dr. Schreiber helps run Summit ElderCare, one of the largest programs of that bunch. Launched in 1995 as a subsidiary of the Worcester, Massachusetts-based health plan Fallon, Summit cares for nearly 1,200 PACE participants across five sites in the Bay State, plus one location in Buffalo, New York.

“PACE has been around for almost 50 years,” Schreiber said. “It’s still here, and it is one of the only validated models of care that has really been shown to improve quality, lower costs, improve quality of life and boost person-centered satisfaction. It checks all the boxes.”

Not every PACE operation is the same, but most work by melding center-based services with comprehensive in-home care. Summit, for example, coordinates services from social workers, nurses, rehab specialities and eight other disciplines.

“The key, the secret sauce to PACE is the interdisciplinary team,” Schreiber explained.

Moving toward the home

In its design, PACE was originally created as a way to keep people living healthy at home and out of long-term care facilities, which in turn cuts costs for the U.S. health care system. To be eligible for PACE, individuals must be 55 or over and in need of nursing home-level care, as certified by a physician.

PACE payers include Medicare and Medicaid as well as Medicare Advantage.

As Schreiber pointed out, the model itself has been around for decades. But it has never received more attention, partly due to the ongoing spotlight placed on nursing homes, which continue to recover after months of deadly COVID-19 outbreaks in 2020 and early 2021.

To avoid having its participants go to skilled nursing facilities (SNFs), Summit actually set up a field SNF, according to Schreiber.

“We knew that there would be people who ended up COVID positive but did not want to go to the hospital or skilled nursing facility,” he said. “Maybe that was not part of their goals, or maybe they did not want to go to a nursing home because they wouldn’t be able to be seen by their families. We needed to have an alternative, so we developed a temporary COVID-19 infirmary at our newest summit site in Worcester.”

In many ways, the ability to turn on a dime and launch an emergency-use SNF reflects one of the PACE model’s biggest strengths: its flexibility. Because PACE organizations house so many different services under one roof, they can promptly pivot when needed, adding to one offering while subtracting from another.

That’s exactly what CHA PACE did to best serve its communities during the public health emergency, its executive director, Jed Geyerhahn, told HHCN.

For starters, the Cambridge, Massachusetts-based CHA — a part of Cambridge Health Alliance, a hospital-based health system — closed its physical center and leaned into its already robust home-based care capabilities.

“We’ve always been more of a home care-based PACE program,” Geyerhahn said. “Most PACE programs are very center-based, bringing most of their participants or a good portion of their participants into the center. But space is such a premium in Cambridge and that metro area, there’s never been a lot of that center space here, so we’ve always provided a lot of home care.”

Established in 1996, CHA PACE serves more than 465 participants. Roughly 40% of its growth has come in the last five years alone.

“We didn’t have to get people used to the idea of providing care in the community, because that’s already what they were doing,” Geyerhahn said. “And likewise, [our staff members] were all equipped with laptops and phones, because they primarily provided care in the community already.”

The future of PACE

In light of the model’s successes in the midst of the pandemic, PACE is positioned to gain participants as more older adults and their family members look to avoid the traditional nursing home.

Overall, participants enrolled in PACE were at one-third the risk of nursing home residents for contracting COVID-19, statistics from the National PACE Association suggest.

But PACE is similarly set up to be an alternative to long-term care in-home care, which can be costly when home health aide or nursing services are needed on a 24/7 basis. That’s particularly true as organizations follow CHA’s playbook by rebalancing the PACE model toward home-based care.

Summit ElderCare kept its center open for a small number of participants who couldn’t go without an intensive level of care, but it too invested more resources into home-based care.

“We knew in March, when the outbreak started, that much of the care was going to have to be done in the home,” Schreiber said. “Overnight — and I would say this happened with almost every PACE organization in the country — we had to go from a site-based model of care to a home-based model of care.”

“Flipping the switch” was made possible with the assistance of technology, he added.

“Telehealth became a model of visits, again literally overnight,” Schreiber said. “Thankfully, many of our providers and teams had iPhones. So we did a lot of FaceTiming. But we were also able to use other types of modalities, in terms of telehealth.”

PACE hasn’t always been supported on a federal level, but that is starting to change. In fact, a recently published budget report from the House Appropriations Committee obtained by HHCN identifies PACE as a major priority.

“The Committee acknowledges the important role of [PACE] in the lives of over 52,000 participants, by allowing these highly medically complex Medicare or Medicaid beneficiaries to live at home, instead of in a nursing facility,” the report states. “The Committee urges CMS to move forward expeditiously on PACE-specific pilots, authorized by the PACE Innovation Act of 2015, specifically testing the innovative, comprehensive, integrated and fully risk-bearing PACE model of care with new Medicare or Medicaid beneficiaries.”

The for-profit model

The PACE model has historically been nonprofit in nature, as federal restrictions on for-profit PACE providers existed until 2015. With those barriers to entry lifted, an increasing number of for-profit operators are starting to pop up.

There are now five total for-profit PACE providers across the U.S., financial filings reveal. The Denver-based InnovAge (Nasdaq: INNV) — the largest PACE organization currently up and running, by a far — leads that group.

InnovAge, which officially went public in early march, has about 1,900 employees. It serves 6,600 seniors in Colorado, New Mexico, California, Pennsylvania and Virginia.

“I think the IPO is notable in a couple ways,” InnovAge CEO Maureen Hewitt previously told HHCN. “One is that it increases capital. And the second piece has to do with awareness. I mean, this program has been around for many years, and now is the time for PACE to really be that household word for the alternative to nursing home care for that for that patient, and I think this is really going to help.”

InnovAge is twice the size of its closest PACE-focused competitor and more than 30 times larger than the typical PACE operator, according to the company.

Similar to its peers, InnovAge strives to improve participants’ health outcomes and lower health care spending by leveraging an expansive network of services. Its interdisciplinary care teams include a primary care provider, a home care coordinator, a personal care attendant, a driver, a dietician and others.

InnovAge’s referral sources are likewise expansive, with participants coming from hospitals, nursing homes and assisted living facilities, in addition to the community at large.

“If you think about what PACE does and what we provide, we’re really a strong alternative to nursing home care,” Hewitt said.

From 2016 to 2020, InnovAge grew its participant numbers from 3,100 to 6,400. During that same time, the company’s revenue increased from $233 million to $567 million.

As Innovage continues to build on that momentum, even more for-profit programs will likely try to set up shop, backed by payers and private equity interests alike.

Nonprofit organizations like Summit are also well-positioned for future growth.

“From [1995] to now, we’ve grown substantially,” Schreiber said. “Our goal is to continue to grow pretty aggressively over the next several years.”

Massachusetts Explores The Advantages And Potential Challenges Of The Johnson & Johnson Vaccine, WBUR

Massachusetts received 58,000 doses of the Johnson & Johnson coronavirus vaccine this week, the first shipment of what could be a substantial boost in vaccination efforts here and across the country. But it’s not clear how that boost will play out or when it will start. Gov. Charlie Baker says he’s not expecting any more J&J deliveries until late March or early April.

And Baker hasn’t spelled out how Massachusetts might target the J&J vaccine given its unique advantages: it’s a single dose shot, and it can be moved around a lot — even jostled — without risking stability.

We have some information about how hospitals, health centers and other vaccination programs plan to integrate J&J, but first, let’s look at some numbers that are getting a lot of attention.

Seventy-two percent of Americans who received the J&J vaccine in trials were protected from a mild to moderate case of COVID-19, as compared to more than 90% for the vaccines from Moderna and Pfizer-BioNTech. The three are similar at preventing the worst outcomes: hospitalizations and death. Public health and medical experts are urging people to get any vaccine offered.

“If someone offered me any one of those three vaccines, I absolutely would be comfortable and would be very willing to take any one of those three,” said Dr. Paul Biddinger, who chairs the vaccine advisory board in Massachusetts.

You Get What You Get

In fact, you may not have a choice. Many hospitals and health centers say they’ll give patients the vaccine that’s available at the time of their appointment because managing the timing, logistics and supply of three different vaccines is complicated enough.

Charles River Community Health, which serves 15,000 mostly low to moderate income patients at clinics in Alston-Brighton and Waltham, has been told to expect alternating deliveries of Moderna one week and J&J the next. Other health centers are getting Pfizer as well. And if patients object to the week and the vaccine they’re offered?

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“We’ll attempt to educate them,” says Charles River CEO Elizabeth Browne. “If patients feel really strongly about one vaccine or the other, we’ll say, ‘We hope you can understand that we need to vaccinate as many people as we can as quickly as possible.’ ”

It remains unclear whether all of the state’s large-scale vaccination centers will begin receiving the J&J vaccine once supplies increase, in addition to Moderna and Pfizer. Tufts Medical Center, which began injecting J&J doses this week, is also not offering or entertaining a patient’s choice.

“That’s for a variety of reasons,” says Dr. Helen Boucher, chief of infectious diseases at Tufts. “The first and most important is that there is no reason to pick one over the other” because all three are safe and effective.

In addition, says Boucher, hospitals may only know which vaccine or vaccines they are getting a few days in advance and for safety, it’s simpler to deliver just one at a time.

Lee Nave, a patient at Tufts Medical Center, says he thought he would be getting Pfizer or Moderna Thursday because the registration process had included booking a second shot. But when Nave arrived for his appointment, he was told the syringe would hold the single-dose J&J vaccine.

Nave remembers a mix of feelings. He had read that J&J was not as good at preventing infections overall but good at preventing serious illness.

So, he decided, “If this is one you’re offering me, I’ll take it. And it also seems very convenient to have one shot and get it out of the way,” Nave says.

Lee Naves shows paperwork he received shortly after he was given the Johnson & Johnson vaccine at Tufts medical center. (Courtesy Lee Naves)
Lee Naves shows paperwork he received shortly after he was given the Johnson & Johnson vaccine at Tufts medical center. (Courtesy Lee Naves)

Boucher says most patients she talks to are thrilled to get vaccinated. Still, she’s hearing some questions. Some patients are concerned that the J&J vaccine relied on cells derived from abortions during vaccine development.

The Boston archdiocese said in a statement that Catholics can request a specific vaccine but should not delay getting inoculated if their choice isn’t available.

“We hope that they will ask questions, receive the relevant information about that teaching, and not delay in their acceptance of the vaccination — whichever approved vaccine is offered — when it becomes available to them.”

One and Done

There’s some early evidence of strong interest among Massachusetts residents in the J&J vaccine. In Barnstable County, 1,200 appointments posted online on Friday were gone in 35 minutes.

Some people, like Nave, may prefer the convenience of booking and showing up for a single appointment, and those who dislike shots will appreciate the option of just one jab. There’s also some evidence of fewer side effects from the J&J vaccine, perhaps because it is just one shot. Symptoms like headaches, fever and nausea are more common with Pfizer and Moderna after the second shot.

“We already had people asking for it,” says Dr. Joanna Duby, medical director at Element Care PACE, a program for high risk elders who want to stay in their homes. The program expects to receive some J&J doses for the first time next week.

Element Care runs six PACE clinics across the North Shore and Merrimack Valley. Duby says bringing participants in for one shot rather than two will make logistics much easier. Before COVID, the program’s wheelchair-accessible vans could carry up to 12 people at a time. Now, with safe distancing, it’s one or two people.

“So you can imagine that with a decent size clinic it takes a lot of trips back and forth to bring these people in,” says Duby.

Targeting Homebound and Homeless Patients

Baker has suggested that the J&J vaccine might be especially useful for some hard to reach populations, such as residents who rarely leave their homes and people who don’t have stable housing. The vaccine does not come with the warnings about limiting transportation of the vials to avoid breakdown that accompany the other two available vaccines. But it does have other limitations that will make it hard to use with homebound seniors and other patients.

Here’s the issue: the five doses in a J&J vial must be used within two hours once the vial is punctured — or within six hours if kept refrigerated at 36-46 degrees. That’s easy in a clinic but very difficult for a traveling nurse who must sit and observe a patient, in their home, for 15-30 minutes after the injection.

“If we’re using this for the homebound, it has to be quick,” says Duby, “or we’ll have to have a monitored cooler when transporting it to homes.”

Baker has also mentioned using J&J for mobile vaccination clinics.

Some programs that work with clients who don’t have stable housing are looking forward to receiving the J&J vaccine.

“A one-dose vaccine that is highly effective will be more easily administered to people experiencing homelessness,” said Dr. Jessie Gaeta, chief medical officer at the Boston Health Care for the Homeless Program, in a text. “It’s helpful to avoid the need for second doses when people have to necessarily move around frequently, don’t have stable housing or a reliable address or phone number.”

The state’s vaccine advisory committee is looking at whether there are other populations for whom the J&J shot might work best.

Once supply of the J&J vaccine ramps up, it looks like there won’t be any bonus doses.  Pharmacists say that although they get an extra dose out of Pfizer and many Moderna vials, they don’t get six doses out of the five dose J&J vials.

Beverly Harborlight House Staff, Members Get Vaccinated, Beverly Patch

Element Care helped deliver the second dose to the at-risk and low-income seniors on Thursday.

BEVERLY, MA — Patricia Jackson admits she was nervous about getting a coronavirus vaccine shot when they first became available. It was only after talking to her doctor at Harborlight House that she decided it go for it.

“She went over everything about it and made me feel better,” Jackson said, “so I was like, ‘Cool, let’s do this.'”

On Thursday, Jackson was one of 18 members and 22 staff at Harborlight who received their second shot through a clinic held through a community partnership with Element Care out of Lynn, which supports vulnerable and low-income seniors on the North Shore.

“I was happy with how fast Element Care was able to get the COVID vaccine shots outs to all of us in the program as I know a lot of folks were struggling to find one,” Jackson said.

Element Care registered nurses Jessica Etten and Heidi Connolly helped administer the shots.

“Our seniors rely and count on us so we are making sure to get the vaccine out to them as quickly as possible,” Connolly said. “It’s nice to see the light at the end of the tunnel.”

“After a long and hard pandemic it’s great to finally be able to get the vaccine to our participants and see some hope for a chance at normalcy again,” Etten agreed.

Element Care will next be in conjunction with the Newburyport Health Department at the Newburyport Council on Aging on Sunday.



LYNN — A new round of vaccinations will be going out to Lynn seniors next week, in the Commonwealth’s drive to get elderly people protected against COVID-19.

The new drive will be conducted by Element Care PACE, a Lynn-based elderly care organization that provides care to seniors who live independently, and will be focused on seniors that are in Element’s care.

“Our goal is to get the vaccine out as quickly as possible and as safely as possible, and to not waste any of it,” said Dr. Joanna Duby, the medical director at Element Care PACE.

The organization registered with the Massachusetts Department of Public Health (DPH), and received its first doses from the state this past Tuesday.

Element has already vaccinated its staff and will begin vaccinating hundreds of seniors at two clinics in Lynn next week.

Duby has found a strong interest in vaccinations among the population she works with.

“The seniors are the ones who want it more than a lot of younger people, because they’re the ones who have seen the devastating effects of the virus on them and their friends,” said Duby, who reported that approximately 180 of the 1,000 patients Element Care PACE works with had contracted the virus, and more than 50 patients had died.

“It’s been devastating. In addition to the risk of getting the virus, the social isolation has been awful,” she said. “They can’t eat with their friends, they can’t see their families, and it’s taken a huge toll on their mental health and their physical health.”

Duby said the process of getting the vaccinations set up was difficult, and that she wished seniors could have had access to the vaccines sooner.

“It’s been a challenge,” said Duby. “It’s hard to know when you’re getting a vaccine, how much you’re going to get, when you’re going to get it. We hoped that the rollout for seniors would be sooner, especially for places that have been hit hard like Lynn.”

As of February 1, residents 75 and older became eligible for the COVID-19 vaccine as the state opened the second phase of its vaccine distribution plan. However, that rollout has been blasted by state representatives and elderly organizations for being overly complex.

People 75 or older are asked to apply for a vaccination appointment through the state website, Duby reported that her organization was uniquely equipped to assist its seniors with navigating this process since its staff have close relationships with the individuals they care for and can provide them with vaccination information directly.

For other Lynn seniors, the process of getting registered has been more difficult.

Rosemie Leyre, 78, a Lynn resident, encountered several issues with the website when she tried to apply for a vaccination this week.

She found out about the vaccination process opening to seniors 75 and older from a neighbor, and went to the state website to apply. She entered her location and her zip code, as was requested by the site, she said.“It said this zip code does not exist,” she said. “Then I got a message that said ‘try again in 24 to 36 hours.’ And I had a few friends who had had the same experience.”

Eventually, she was able to apply through the “Patient Gateway” portal from Massachusetts General Hospital and scheduled an appointment for Wednesday evening at a Lynn site.

Leyre said her friends were very interested in getting the vaccine as soon as possible.

“The people I know are all very positive towards the vaccine,” she said.

Of the group of people she knows, she said only one of them was skeptical of the vaccination.

A Belgium native, Leyre hopes that once the virus subsides she will be able to visit her daughter, who still resides in her home country.

“I can’t believe how long it has been since I traveled,” she said.

Guthrie Scrimgeour can be reached at

Thousands of Massachusetts hospital staff expected to begin getting long-awaited COVID-19 vaccinations next week

Staff and residents at senior care facilities may be only days behind

By Deanna Pan and Robert Weisman Globe Staff,Updated December 11, 2020, 7:03 p.m.

The Food and Drug Administration Friday night approved the first COVID-19 vaccine in the United States for emergency use, clearing the way for the first Massachusetts residents to receive inoculations as soon as Tuesday, as hospitals and senior care facilities say they can begin immunizing staff and residents within hours of receiving their shipments of the precious cargo.

Shipments of the two-dose regimen from drug makers Pfizer and BioNtech, packed in dry ice, should be en route to hospitals on Monday or Tuesday, officials said.

Within 24 hours of receiving their first shipment, officials at the state’s largest hospital system, Mass General Brigham, will be able to vaccinate a limited number of employees, said Dr. Paul Biddinger, the system’s medical director for emergency preparedness. He said the system, which includes Mass General and Brigham and Women’s hospitals, expects to ramp up vaccination capacity before the end of the week.

“We want to start with a minimum across the enterprise of 1,000 employees a day, but we want to actually be able to accelerate beyond that relatively quickly,” Biddinger said. “We’re hoping it’s only a matter of a couple of months to get us through the majority of our workforce.”

Mass. hospitals hope to administer COVID-19 vaccine to some workers as soon as next week

Dr. Saul Weingart, chief medical officer at Tufts Medical Center, said he anticipates the hospital will receive its first 975 doses on Monday, and begin offering the vaccine to employees in “patient-facing” areas shortly after that.

“So we would potentially have about 1,500 to 2,000 staff members who would be eligible to receive the vaccine, and our expectation is we would get it into them all in a six-week period,” he said.

Boston Medical Center, meanwhile, is preparing to roll out its staff vaccination program on Dec. 16, the day after the hospital expects to receive its shipment of two trays containing 975 vaccines each. BMC has already hired temporary nurses on contract to begin administering shots.

The hospital is still finalizing which employees will be offered vaccinations first, explained David Twitchell, BMC’s chief pharmacy officer, with staff who are at risk of exposure to COVID-19 receiving priority. Employees will be notified of the opportunity to schedule their vaccination appointments in randomized batches of 300.

“We’re trying to be transparent [about the process],” he said. “It’s not about one person being more important than the other; it’s about trying to have a rational way of rolling this out.”

Governor Charlie Baker this week announced a plan to offer the first vaccinations primarily to health care workers and seniors in long-term care facilities. He expects the state to receive 300,000 doses of the vaccine by the end of December, although this is contingent on the FDA giving approval to vaccines developed by Pfizer and Cambridge-based Moderna.

Mass. lays out COVID-19 vaccine timeline, but most will have to wait till spring

The FDA advisory committee is scheduled to debate whether to allow emergency use of Moderna’s vaccine next Thursday.

Both vaccines require people to get two shots a few weeks apart to be maximally effective; the shots also must be kept at extremely cold temperatures to prevent the vaccines from spoiling. As a result, the first shipment of Pfizer’s vaccine is being delivered only to Massachusetts hospitals equipped with ultra-cold freezers.

Senior care sites are hustling to set up their own vaccination spaces, ready consent forms and protective gear, and reassure skeptical health workers and seniors that the vaccines are safe and effective.

“This is an entirely new experience,” said Matt Salmon, chief executive of Salmon Health and Retirement, which hopes to vaccinate 700 residents and 1,500 staffers at a half dozen skilled nursing facilities across central Massachusetts over the coming weeks. “In the history of nursing homes, we’ve never had to do mass vaccinations in such a short period of time.”

Some senior care facility administrators have been told vaccinations at their sites will start on the week of Dec. 21 or the following week. But they are clamoring for more information from federal health authorities and from their contractors, CVS and Walgreen, which will administer the vaccination clinics, on how it’s all going to work.

“Operators are living in fear that they’ll just get a knock on their door,” and the vaccinations will begin without adequate preparation, said Tara Gregorio, president of the Massachusetts Senior Care Association.

While the pharmacy companies have promised to bring the equipment needed to handle the injections and have hosted webinars providing basic information, senior care operators say they’re still in the dark on key points, such as clinic hours and expectations of their staffs.

The companies, following federal guidelines, have committed to making only three visits to each nursing home, rest home, and assisted living center to administer the two-dose regimen — a schedule operators say is far too compressed to vaccinate hundreds of staffers working in three shifts. Some fear that side effects of the vaccine could cause temporary staff shortages if everyone is vaccinated at once.

“We have a lot of ground to cover between now and when the vaccinations start,” Salmon said. “If we don’t coordinate on this, it’s not going to be as effective as it could be.”

Assisted living administrators, meanwhile, are waiting to find out how many initial doses they will receive from the state. They’re also cautioning against letting down their guard at a time when virus infections are rising in senior facilities.

“We want to lean into best practices in infection control in assisted living now as we see the light at the end of the tunnel,” said Brian Doherty, president of the Massachusetts Assisted Living Association.

Some organizations employing home health care workers have registered to receive vaccine supplies from the state Department of Public Health. Front-line workers who help home-bound seniors are in the high-risk group set to be vaccinated first, but details of how and when they’ll get their shots remain to be worked out.

“As soon as we can do it, we’re ready to go,” said Dr. Joanna Duby, medical director at Element Care in Lynn, a nonprofit that sends more than 100 nurses, personal care assistants, physical and occupational therapists, and other workers into the homes of elderly low-income residents. “In terms of when we’re going to get the vaccine and how we’re going to get it, we’ll wait to hear.”

Staff at senior care facilities have gotten used to adjusting to fast-changing conditions since the COVID-19 pandemic began last spring, but Salmon of Salmon Health and Retirement, said preparing for vaccinations on short notice without adequate information may pose the biggest challenge yet.

“This is a whole new level of flying by the seat of our pants,” he said.

At Mass General Brigham, by contrast, administrators are well along planning a rapid mass vaccination. They’ve divided the work force into four waves, starting with staffers involved directly in COVID-19 evaluation, testing, and care. The hospital system also is launching a feature on one of its smartphone apps that will allow staff to schedule their vaccination appointments.

“We want to try and make it through each of the wave as quickly as we can,” Biddinger said.