Surrounded with Services

by Shawn Bloom

Posted on: June 7, 2011

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In the discussions about health care reform, long-term services and supports are often far in the background. Policy makers don't like to discuss it and most people, even with faced with it, don't like to think about it.

However, remarkably, many of the concepts that policy makers and health care experts agree are needed to reform health care already exist in the long-term care model, the Program of All-inclusive Care for the Elderly (PACE). While patient centered care, accountable care organizations, and bundled payments may be hard to incorporate into the general health care delivery system, these concepts have been essential to the success of PACE .

The PACE model was not imagined from a set of abstract ideas. It started because the Chinese American community in San Francisco wanted to find a way to keep their aging elders at the center of their families and communities. As a result, visionary Marie-Louise Ansak, was hired to help the Chinatown community in San Francisco find a way to care for their aged family members. She developed a care delivery model based on the concept of the British day hospital. As a result, On Lok opened the first adult day care center in 1973. The center was able to provide the services that a nursing home would offer, but the participants returned to their home at night.

Over time, On Lok found that serving individuals with complex medical, social, and sometimes mental health needs could not be effectively done through the limited menu of benefits reimbursable under Medicare and Medicaid. Often these programs would not cover common sense interventions that would save money, particularly in hospital and nursing home costs that could have been avoided. On Lok approached the state of California and the Health Care Financing Administration (now CMS) to propose receiving a bundled payment for each enrollee, through which On Lok would manage all of the participant's care and services.

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With this flexibility, the program could focus on ways to support the participants desire to stay at home and in the community. PACE provides primary care, personal care, pharmacy, physical therapy, occupational therapy, home care, transportation and support and training for family caregivers, home modifications and access to nontraditional medicine that would not be covered under the traditional fee for service Medicare and Medicaid program.

The federal government and the state were supportive because On Lok could provide this high level of care with a bundled payment that was both predicable and less than what these individuals would be expected to cost Medicare and Medicaid in the fee for service system. The key was On Lok's willingness to provide an all-inclusive benefit so that the risk for hospital and nursing home use was the program's and not the government's. This meant that On Lok's financial incentives were perfectly in line with its clinical incentives and the participant's goal of remaining in the community as long as possible.

With volume based fee for service billing no longer at the center of the care delivery model, the key key to PACE became the use of an interdisciplinary team to plan and delivery care. The team includes primary care, social work, OT, PT, transportation, nutrition, personal care, nursing, activities and others. Typically the team will meet daily to discuss hospitalizations, changes in status, and consider possible revisions to care plans. Because members of the team are also the participants' primary caregivers they can closely monitor the effectiveness of the care plan they develop. Each team can effectively manage the care of 150 to 200 individuals.

Since it's evolution at On Lok in San Francisco, the PACE program has expanded to include 75 sponsoring organizations in 28 states. In order to enroll in PACE a person must be certified by their state to need a nursing home level of care; be 55 years old or older; live in a PACE service area; and be able to live safely in the community at the time of enrollment with the support of PACE services. The success of PACE is now reflected in ideas that health care reform seeks to implement throughout the health care delivery system.

Community-based: PACE is focused on helping participants remain the community for as long as possible. Community-based care is more desirable to consumers, less expensive and provides a higher quality of life than institutional care. The PACE model can, when appropriate, support family caregivers through training and respite care. PACE provides transportation, home care and adult day services. Because the members of the interdisciplinary team have regular face to face contact with each enrollee it is able to effectively manage each participant's care.

Comprehensive: PACE organizations provide preventive, primary, in patient and institutional care across all care settings. Traditional fee-for-service providers often must operate under a menu of care and services for which they can be reimbursed. PACE organizations have been operating with bundled payments for over 20 years. Bundled payments provide a way to have the resources to focus on the most effective care for each individual rather than making considerations about what service is reimbursable and what service is not.

Accountable : PACE organizations are accountable because they can not shift the costs to other providers when a participant becomes more complicated. PACE has the financial incentives to provide effective primary and preventive care to avoid in patient unitization later. When and if a PACE participant needs hospital or nursing home care, PACE pays for and coordinates that care without extra payment from the government or the individual. Taking on the financial risk of more expensive care ensures that the PACE program is accountable to providing high quality care and services at all times.

PACE organizations see themselves as well positioned for the future. PACE is a proven model of care that represents many of the core concepts driving health care reform. As a community-based option to institutional care, PACE is able to help people live in the community for as long as possible.

Shawn Bloom is President and CEO of the National PACE Association, the organization representing the 75 Programs of All-Inclusive Care for the Elderly.

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