No need for nursing home if PACE handles senior care

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By Andrea Pitzer, Special for USA TODAY
CAMBRIDGE, Mass. — Theresa Doherty, 76, has a black knit suit and a rhinestone elephant brooch. She’s also on the cutting edge of modern health care.
In a Cambridge Health Alliance center on Green Street, Doherty, who has heart disease, and others sit in the narrow halls waiting for appointments while staff members and patients call out hellos, using first names. Patients play bingo and get ready for lunch in two activity rooms. A nurse dips her head into an office and mentions a patient’s hand tremors to Rachel Broudy, medical director of the alliance’s Program of All-Inclusive Care for the Elderly (PACE).

"Families are feeling like we’re failing our elders," Broudy says. "And so PACE tries to keep people who are eligible for nursing home care living independently in the community."

Broudy treats Doherty and nearly 200 other PACE patients at the center — almost all of whom qualify for both Medicare and Medicaid. They are supported by a coordinated medical team that the federal government hopes will cut costs and improve life for the elderly.

How PACE works

According to the National PACE Association, there are 16,000 patients in PACE nationwide. The average client is 80 and takes eight prescription medications. Participants have to be 55 or older, certified by their state to need nursing home care and be able to live safely in the community.

Each program receives a fixed amount per person from a patient’s state Medicaid program — usually 85% to 90% of estimated nursing home costs. Medicare funds come through a risk-adjusted formula in which the program receives more for sicker enrollees.

PACE becomes both the patient’s insurer and care provider and is obliged to pay for all of the patient’s medical care from the point of enrollment forward.

"Before, I was paying almost $1,000 a month for prescriptions," Doherty says. She taps a finger on the table in front of her. "And now — nothing."

PACE’s dual role allows for flexibility in using the money that comes in from the federal government. Anne Fabiny, chief of geriatrics at the Cambridge Health Alliance, lists items such as glasses, dental care, window air-conditioner units and better shoes as typical things less likely to get covered or obtained via traditional health care programs. Part of the idea is that thorough preventive care can prevent more serious conditions and reduce hospitalizations.

Not only is hospital care staggeringly expensive, Fabiny says, but hospitals are dangerous places for seniors. "You don’t want the elderly there a day longer than necessary," she says. "And you only want them there if they really have to go."

Started in the 1970s as a community project to keep elders in their homes, today PACE provides a ride back and forth to its centers for day-care activities and medical appointments. Along with the nutritionist, social worker, psychologist, activity director, nurses’ aides, nurse practitioner, doctor and others, the driver is a part of the health care team that meets daily. The clinical staff members also hold group meetings at least twice a year with each patient.

Because the amount received for an individual is fixed, says Shawn Bloom of the National PACE Association, the program has every incentive to keep patients as healthy as possible. "If we provide good care," Bloom says, "we control costs."

The big picture

Robert Kane, director of the Center on Aging at the University of Minnesota, says PACE has provided some important lessons on the value of integrating all the players on a patient’s medical team and having staff touch base routinely with patients outside of scheduled medical appointments.

Yet, Kane says, only about one in five people eligible for nursing home care actually ends up getting it. "When it comes to PACE patients, you hear, ‘There but for the grace of God I’d be in a nursing home,’ " Kane says. "But all those people wouldn’t go to nursing homes. A substantial portion would be in some kind of community-based care system."

Kane says such care runs the gamut from home care to assisted living to adult foster care. This care often costs much less than a nursing home, but nursing home expenses are the standard by which PACE appears to save money.

What’s more, says Bruce Robinson, chief of Geriatrics at Sarasota Memorial Hospital in Florida, if PACE expanded greatly, the system might not be able to bear the cost. "It’s not a criticism of PACE itself," he says. "Yet if you do the math, you’re going to say we can’t afford this for the country — not with all the Boomers coming along."

But for the time being, Broudy hews to the PACE approach in Cambridge. And she likes the results. "I think we take care of these people in an extraordinary way," she says. "The care and dignity we provide to largely disenfranchised patients — that is extraordinary."


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