PACE Programs Continue to Innovate

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.”