Health Care Delivered as It Should Be

The New York Times
The New Old Age: Caring and Coping
Health Care Delivered as It Should Be
January 8, 2009
Jane Gross

Hardly anyone has a good word to say about this country’s fragmented system for delivering and paying for long-term care, with one exception: the PACE program, which many experts laud as long-term care done right.

PACE, an acronym for “program of all-inclusive care for the elderly,” provides anything and everything a frail elderly person and her family might need, coordinated by a team of medical and social service providers, for an annual fee generally paid by Medicare and Medicaid. The care can be delivered at home, a PACE center, a hospital or a long-term care facility — seamlessly moving back and forth under the supervision of one interdisciplinary team for a fixed cost.

The model for PACE was developed 27 years ago in San Francisco’s Chinatown/North Beach area by a community center called On Lok (Cantonese for “peaceful, happy abode”). The On Lok approach was replicated elsewhere using foundation grants and gradually embraced by Congress, which eventually authorized all PACE programs as Medicare providers.

The formula is hard to quarrel with. According to several studies, PACE clients, while far more frail than the average Medicare recipient, cost taxpayers less money in government-funded medical care, have fewer and shorter hospital stays, rarely wind up in nursing homes (even though they must be eligible to enroll in one), and report satisfaction rates close to 100 percent.

Readers of this blog, physicians, researchers in geriatrics and gerontology, clients and family members — all have urged that I visit a PACE center, and so recently I did.

The nation’s largest PACE provider is the Comprehensive Care Management Corporation in the Bronx. What I found there is a model that bridges the customary divide between acute and chronic care, and assigns each client to an interdisciplinary team that coordinates care across different settings. The program pays for coverage as a H.M.O. would, with a fixed annual cost per patient rather than a fee-for-service set-up.

But unlike many H.M.O.’s, the program doesn’t operate as a faceless bureaucracy serving as gatekeeper to all but primary care physicians, and granting and denying services or procedures. Rather, at 40-odd locations in 22 states, PACE means care by an interdisciplinary team that knows the patient and family, their histories, strengths, limitations and goals. Team members decide the care plan with each member, tweak it as things change, and rarely say ‘no’ to anything that will sustain quality of life.

PACE offers its members access to primary care physicians, specialists, home health aides, transportation, recreation and companionship at a day center, meals (at the center or delivered to home), medical assistance on call 24-hours-a-day — and just about anything else that will make it possible for extremely frail and cognitively impaired elders to remain at home.

The breadth and flexibility of PACE’s services were apparent during a daily team meeting in late December, on the eve of a snow storm. First the assembled doctors, nurses, social workers, rehabilitation and recreation specialists, transportation coordinators, clinic schedulers and office managers reviewed the overnight emergency calls. These had been answered by a real person who had assessed whether a trip to the emergency room was needed or the problem could be handled by phone or with a home visit, always the goal. One person hospitalized overnight because of seizures had already received a dawn visit from her regular PACE doctor, with reassurance that her home health aide was on standby for her return and that her missing coat had been located.

The team then discussed new clients and those needing changes in their care plan: a woman who felt well enough to come to the center five days a week and thus required a new transportation schedule; a hospitalized patient ready for discharge whom they hoped to keep to keep longer, since his wife needed a break from caregiving; a new member who’d asked for more fresh fruits and vegetables among the daily lunch choices.

Next came a review of everyone who had been expected that day at the center on Allerton Avenue — one of seven run by C.C.M. in the New York metropolitan area — but had not shown up yet. Some were out of town visiting relatives, others at outside medical appointments or under the weather. A few had been stranded by transportation glitches. Anyone unaccounted for — and there were only a few — would be called or visited immediately, especially with the storm bearing down.

All PACE members are ranked by priority. Level 1 means they can’t be alone at home without an aide. Level 2 means they need someone to shop, organize medications or otherwise make a short home visit every day. And level 3 means they are either safe alone or have family or neighbors for back-up support. Since weather reports suggested the center might have only a skeleton staff the next day, arrangements were made to get aides, food, backup oxygen tanks and whatever was needed to each of 300 clients classified at levels 1 or 2. For level 3 clients, staff would double check that relatives and friends hadn’t all decamped for the holidays.

Outside the meeting room, three staff physicians were seeing patients. On certain days, they are joined by a wound care expert, since pressure sores are an abiding problem for those who spend all their time in bed or in a wheelchair. Also available are two psychiatrists specializing in depression, anxiety and dementia-related agitation; an ophthalmologist and optometrist to treat the myriad of vision problems associated with age; and a podiatrist, because many older people cannot cut their own toenails and risk infection or diabetic complications if the job is not done regularly and carefully.

Other specialists, on contract from a local hospital, see patients in their own offices, with transportation and translation provided by PACE, as well as immediate consultation between the primary care doctor and the specialist.

In the recreation and dining areas, members are welcome for breakfast and lunch and sent home with dinner. At the Allerton Ave. center, located in an area with a large Latino population, someone reads newspapers aloud in Spanish every day, down to the horoscopes and the box scores.

Staff members take notice if anyone is making frequent trips to the bathroom, and a nurse is on hand to check for a urinary tract infection, another condition especially dangerous for the elderly. The center has handicapped-accessible showers for those who can’t use the ones they have at home, as well as washing machines and dryers. Some clients manage but one visit a week; others come daily. All are provided free transport, with an aide if necessary, but also have the option of many of the same services at home.

All PACE members nationwide must be 55 or older and eligible under state regulations for nursing home placement, which generally means they require assistance or supervision with basic tasks like bathing, dressing, walking or getting from bed to a wheelchair. Medicare, which provides health coverage for all Americans over the age of 65, pays a share of the “capitated” annual free per member. Medicaid pays the remainder for those who qualify on grounds of low income.

Anyone otherwise eligible for PACE but not covered by Medicaid can make up the difference out-of-pocket, which in New York State would be around $3,500 a month — a tidy sum but far less than the cost of home health aides, assisted living with the enhanced services people this frail would need, or placement in a skilled nursing facility. In other words, this excellent care is not limited to the indigent, as it is in many other pilot programs run by Medicaid.

Each PACE program must manage its funds wisely, lest the cost of services exceeds the fixed fees. That encourages preventive care that members might not receive otherwise. For instance, government reimbursement and most private insurance will not pay for ongoing physical therapy once a patient has “plateaued,” and so often treatment stops, which can lead to further loss of mobility. But since physical therapy is cheaper than repairing a broken hip or providing round-the-clock care for someone who is bed-bound, PACE does pay for ongoing physical therapy, an approach that is cost-effective to the taxpayer, according to several studies, and leads to better outcomes.

After a day at the PACE center, my only reservation is whether a middle-class person — say, my mother — would have given a program like this a chance or been put off by the race, ethnicity or cultural differences of the other clients. She was by no means a prejudiced woman, but the older she got the more her comfort level depended on being among people of similar background.

I was embarrassed to raise this question. But, PACE officials told me, my mother’s resistance would not have been unusual or viewed as a sign of bad character. Shared experience matters at this time of life, and PACE centers tend to reflect the neighborhoods where they are located. My mother might have done well at C.C.M.’s Westchester County center, in White Plains, N.Y., or a center in Amityville on Long Island that is soon to open.

PACE centers around the country are listed on the Web site of the National PACE Association, along with program details. Further information is available through the Centers for Medicare & Medicaid Services. My thanks to all of you who told me to go take a look.



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