Frailty scores, aging in place, connecting seniors with PACE programs
BY LISA SIMMONS-FIELDS, DNP, MSA, RN, CCM, CPHQ, FCM, AND ANNE LEWIS
Introduction
Our aging population is growing at a much faster rate than in the past. “By 2030, 1 in 6 people in the world will be aged 60 years or older” (WHO, 2024). As case managers, we know older age can come with chronic conditions with underlying factors such as frailty, urinary incontinence, falls, pressure ulcers and delirium. Evidence suggests that if people live in a supportive physical and social environment, this will enable people to do what is most important to them regardless of changes in capacity (WHO, 2024).
Case managers working with aging populations need to be able to link patients with resources in the community. The Program of All-Inclusive Care for the Elderly (PACE®) is a comprehensive, high-touch, provider-based health plan for frail, complex individuals who require a nursing home level of care. PACE programs provide comprehensive care that is coordinated and includes wrap-around services to support the elderly. PACE supports aging in the home and allows frail elders to continue to live in the community for as long as possible. Research has shown that participation in PACE programs reduces emergency department visits, hospitalizations and nursing home stays.
Background
There are 180 PACE organizations operating in 33 states and the District of Columbia. More than 300 PACE centers serve over 79,000 participants across the country. Based on National PACE statistics, 94% of PACE participants continue to live in the community. Authorized by the Balanced Budget Act of 1997, PACE covers all Medicare Parts A, B and D benefits, all Medicaid-covered benefits and any other services or supports that are medically necessary to maintain or improve the health status of PACE participants. PACE uses a capitated payment model and provides all necessary care while assuming 100% of the financial risk. By accepting full financial risk, PACE can ease strains on state Medicaid programs by providing care and services at less cost than the traditional fee-for-service models for like populations. Delivering the full scale of services needed for this frail population requires a value-based approach by Interdisciplinary Team (IDT) members who have a whole person-centered focus on prevention, meeting current needs and positive health outcomes.
PACE organizations receive fixed per-member per-month payments depending on participant eligibility for Medicare, Medicaid and private payments (for program participants who are not dually eligible). Individuals not qualifying for Medicaid can participate, but monthly premiums are equal the amount of the state’s Medicaid payment. This type of bundled payment results in the prevention of duplicate services and encourages the use of timely, coordinated and less expensive community-based alternatives to expensive hospital and nursing home care. In PACE there is never a co-pay, deductible or coverage gap so participants can access the care, services and medications that they need.
Criteria
To be eligible for the PACE program, individuals must be 55 or older, although the average age of a PACE participant is 76 years old. They must have multiple, complex chronic conditions, cognitive and/or functional impairments that meet the state’s nursing home level of care criteria. They also must live in a defined PACE service area. While PACE does not have financial eligibility requirements, approximately 90% are dually eligible for both Medicare and Medicaid. Individuals must also be able to live safely in the community at the time of enrollment with the help of PACE services. Because both PACE and hospice are Medicare benefits, an individual may not be enrolled in hospice and PACE simultaneously
Benefits
Once enrolled, PACE members, known as participants, are cared for by an interdisciplinary team (IDT). The IDT includes doctors, mid-level providers, nurses, therapists, social workers, dietitians, personal care aides and transportation drivers. After an initial comprehensive assessment, the IDT creates an individualized care plan that includes comprehensive services to meet participant care needs 24 hours a day, seven days a week, 365 days a year and across all care settings. Participants are assessed semi-annually and whenever there is a change in condition and the plan of care revised according to the participant’s needs.
PACE participants attend the PACE center as indicated in the care plan. At the PACE center participants receive adult day health services including meals, socialization, recreational activities and personal care. The PACE center also includes a primary care clinic where participants receive primary care as well as a rehabilitation therapy area where both skilled physical and occupational therapy are provided as well as restorative therapies. The IDT is located at the PACE center, and participants receive care directly from IDT members. The IDT also coordinates and authorizes the payment for services delivered by a contracted network of providers to meet participant needs including, but not limited to, the following services:
- Primary and specialty care
- Outpatient care including behavioral healthcare
- Home care and skilled home healthcare
- Adult daycare
- Durable medical equipment and supplies
- Respite care
- Participant/caregiver education and support
- Transportation
- Hospital care and procedures
- Skilled and long-term facility care
Referrals and Interventions
Case managers, in collaboration with primary care and the care team are in an essential position to identify patients that can benefit from PACE services. Along with patient assessment, CMs can use analytics such as predictive modeling to understand current and future risk and frailty levels to identify patients in need of additional community support to stay safe at home.
Case managers need to ensure they are knowledgeable about PACE programs and partner with PACE representatives, often known as community liaisons, to make referrals of patients who may benefit from PACE services. Early engagement with patients, their families and PACE program representatives will help increase the awareness and understanding of the PACE program and associated services. The PACE enrollment process has a number of steps and requires a state level of care assessment, which may take weeks. The assessment will evaluate medical, cognitive functional limitations that could warrant a nursing home stay and clinical eligibility for PACE.
Conclusion
In summary, PACE programs can support our aging populations’ desire to live safely in their home and in the community setting. Case managers can benefit their patients by educating themselves about the PACE model and availability in their area. Case managers can also proactively identify patients who may benefit from PACE services and engage them, their caregivers and PACE providers in in discussions to determine if these services will benefit them.
References
National PACE Association. Retrieved December 10, 2024, from www.npaonline.org
Span, P. (2022, March 12). Meet the underdog of senior care. The New York Times. https://www.npaonline.org/docs/default-source/default-document-library/nyt-article-underdog-03-12-2022.pdf
U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. (2021, October 22). Comparing outcomes for dual eligible beneficiaries in integrated care: final report. U.S. Department of Health and Human Services. https://aspe.hhs.gov/reports/comparing-outcomes-dual-eligibles.
World Health Organization. Ageing and health. Retrieved December 10, 2024, from: https://www.who.int/news-room/fact-sheets/detail/ageing-and-health
Lisa Simmons-Fields, DNP, MSA, RN, CCM, CPHQ, FCM, serves as the director, System Population Health and Care Management for Trinity Health System, a multi-institutional Catholic healthcare delivery system spanning 25 states. In this role, Lisa collaborates with leadership and teams across clinical, business and community health domains to improve the health and well-being of our patient populations. Lisa is passionate about creating standard evidence-based programs that support high quality patient care delivery systems.
Lisa currently serves as president for the CMSA-Detroit Chapter and is a member of the Editorial Board of CMSA nationally. Lisa also serves as co-chair of the Epic Care Management Advisory Board.
Anne Lewis joined Trinity Health in 2015 and serves as the chief operating officer for Trinity Health PACE. Trinity Health is one of the largest providers of PACE in the country with 13 PACE Organizations operating in 10 states across its ministries. In her role, she leads overall PACE operations as well as strategic planning and program development. She serves as a member of Trinity Health PACE’s National Health Ministry Executive Leadership team and provides leadership, direction and support to the operations of Trinity Health PACE Organizations.
Ms. Lewis has over 30 years of healthcare administration and post-acute care consulting experience and has focused her career on PACE since 2005. In addition to her work in PACE she has significant leadership and operational expertise in the fields of home-and-community based services, managed care and behavioral health.
Ms. Lewis holds a Bachelor of Science degree in psychology and a Master of Arts degree in rehabilitation counseling.
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