|Implemented in this survey?|
The Program of All-Inclusive Care for the Elderly (PACE) is an integrated, acute and long-term care model for frail, disabled adults living in the community. Evaluations have demonstrated the program's success in reducing costs by delaying nursing home care and shortening hospital stays. However, the growth of PACE has been much slower than expected.
The Program of All-Inclusive Care for the Elderly (PACE) is a Medicare program that integrates the delivery and financing of services for older adults who require nursing home level care but are able to safely reside in community settings. PACE organizations provide and coordinate a continuum of medical and social services including primary care, occupational and recreation therapy, home health care, and hospital and nursing home care. PACE enrollees attend an adult day health center where they receive most services from a multidisciplinary care team. Programs often contract out for specialty care, but services continue to be managed and coordinated by the care team. PACE providers receive a capitated payment per enrollee from both Medicare and Medicaid, and assume the full financial risk for all services including hospitalizations and nursing home stays. Providers are required to offer all services in the Medicare and Medicaid programs, but most provide additional services (Eng, 1997).
The overarching goal of the PACE program is to enable frail older adults to live in the community for as long as possible. Evaluations of the program have consistently shown that PACE enrollees have lower rates of nursing home admissions, shorter hospital stays, lower mortality rates, and better self-reported health and quality of life compared to non-PACE populations (Chatterji et al, 1998). In addition, costs for PACE enrollees are 16-38 percent lower than Medicare fee-for-service costs for a frail elderly population, and 5-15 percent lower than costs for comparable Medicaid beneficiaries (White 1998, Bodeheimer 1999).
Despite the success of this model of care, the growth of PACE has been much slower than expected. The 1997 Balanced Budget Act established PACE as a permanent program within Medicare, and authorized 40 new programs that year, and 20 programs each year thereafter. However, by 2008, only 61 PACE programs were operating in 29 states (NPA). While several million adults are potentially eligible for PACE, only 17,000 are enrolled. Lynch et al (2008) reviewed the existing literature on PACE and interviewed PACE program directors, financial officers, and researchers to understand why the program has not expanded and enrollment in existing programs remains limited. They categorized their findings as follows:
In addition to these reasons, states with large rural populations have found it difficult to develop PACE programs. Since PACE uses a day care model, states with low population densities face additional transportation and care coordination barriers (Gross 2004; Lynch 2008). Despite these barriers, the PACE model has influenced the development of community-based integrated care models for frail and disabled older adults.
To provide comprehensive and cost-effective care for frail older adults living in the community.
Capitated Medicare and Medicaid payments to PACE organizations.
Center for Medicare and Medicaid Services, State Medicaid Programs, Older Adults; Private Insurers
|Degree of Innovation||traditional||innovative|
|Degree of Controversy||consensual||highly controversial|
|Structural or Systemic Impact||marginal||fundamental|
|Public Visibility||very low||very high|
The organization and delivery of services in the U.S. is highly fragmented. PACE is a program which integrates acute and long-term services and coordinates the continuum of care for its enrollees.
Approximately 10 million Americans require long-term care services and demand is projected to grow substantially with the aging of the population. Medicaid pays for a large portion of long term care. In 2008, Medicaid paid 40 percent of total long term care expenditures, and 43 percent of nursing home expenditures (KFF, 2009).
During the 1980s, few states provided long-term care services in home and community-based settings. The 1990 Americans with Disabilities Act ruled that States must provide services for disabled individuals in community settings if appropriate. Since then, spending on home and community-based has increased. Medicaid spending on home and community-based services increased from 13 percent of total long-term care costs in 1990 to 41 percent in 2006 (NPA 2004; KFF, 2009).
Both the trend away from institutionalization as well as the need to contain long-term care costs has encouraged the development of innovative care models for disabled populations. PACE was the first program to successfully integrate the delivery of acute and long term care services, and has served as a model for subsequent efforts.
Rising long-term care costs and the need to care for frail older adults in the community.
|Implemented in this survey?|
The PACE model was developed in San Francisco's Chinatown-North Beach neighborhood by On Lok Senior Health Services in 1973. On Lok administrators believed that a neighborhood adult day center was a more culturally appropriate alternative to nursing home care for its largely immigrant population, and could also potentially delay nursing home placement. In 1979, On Lok received a four year demonstration grant from the Centers for Medicare and Medicaid Services. In 1983, it received a waiver from Medicare to combine Medicare and Medicaid financing for its enrollees. In 1986, CMS, the Robert Wood Johnson Foundation, and the John A. Hartford Foundation provided On Lok with funds to replicate its model at 10 additional demonstration sites. The success of these demonstration projects led to its establishment as a permanent program within Medicare (Bodenheimer, 1999).
The approach of the idea is described as:
renewed: The PACE model was first developed by On Lok Senior Health in San Francisco in 1973.
Local level - PACE organizations currently operate in 29 states.
The PACE model was developed at On Lok Senior Health Services in California. Both the Centers for Medicare and Medicaid Services as well as national foundations played an instrumental role in funding and supporting early demonstration projects and evaluations of the On Lok model.
|Center for Medicare and Medicaid Services||very supportive||strongly opposed|
|State Medicaid Programs||very supportive||strongly opposed|
|Insurance companies||very supportive||strongly opposed|
|Private Sector or Industry|
|For-profit provider organizations||very supportive||strongly opposed|
The 1986 Omnibus Reconciliation Act authorized 10 demonstration programs based on the model developed at On Lok in California. These sites were evaluated by CMS in 1991, and in 1997, the Balanced Budget Act established PACE as a permanent part of the Medicare program (NPA 2004).
|Center for Medicare and Medicaid Services||very strong||none|
|State Medicaid Programs||very strong||none|
|Insurance companies||very strong||none|
|Private Sector or Industry|
|For-profit provider organizations||very strong||none|
Regulations governing PACE organizations are set by the Centers for Medicare and Medicaid Services (CMS); applications to become a PACE organization must be approved by CMS. Although PACE became a permanent Medicare benefit, States can choose whether to include PACE in their Medicaid programs. According to regulations, however, PACE organizations must operate under both the Medicare and Medicaid programs in a state. Therefore, if states do not incorporate PACE into their Medicaid plans, providers cannot receive approval from CMS to operate as a PACE organization. After States add PACE as a Medicaid benefit, they are responsible for setting the Medicaid capitation rate, as well as monitoring and oversight of the PACE organization (CFR, 1999; NPA 2004).
PACE organizations are required to submit monitoring data to CMS and the State. Clinical measures include requirements for personnel training, infection control, service delivery, and emergency care. Administrative measures include requirements for fiscal soundness, grievance and appeals processes, and enrollment and disenrollment (CMS, 2008). PACE 0rganizations must also develop an internal quality improvement plan which is approved by CMS and the State (CMS 2008; NPA 2004).
Final evaluation (internal), Final evaluation (external)
Structure, Process, Outcome
Evaluations have shown that PACE enrollees have lower rates of nursing home admissions, shorter hospital stays, lower mortality rates, and better self-reported health compared to non-PACE populations (Chatterji et al, 1998). In addition, costs for PACE enrollees are 16-38 percent lower than Medicare fee-for-service costs for a frail elderly population, and 5-15 percent lower than costs for comparable Medicaid beneficiaries (White 1998, Bodeheimer 1999). PACE enrolles are also more likely to die at home than other Medicare beneficiaries (Temkin-Greener, 2002)
PACE has become a model for community-based programs that integrate acute and long-term services and provide an alternative to nursing home care for disabled populations. However, the number of PACE organizations has not grown as rapidly as expected. Experts agree that the program must be modified if it is to grow substantially.
Locally, several PACE sites have adapted their programs to address these barriers. For example, On Lok in California has developed a program for individuals who are only eligible for Medicare (Bodenheimer, 1999). On a national level, the 2005 Deficit Reduction Act created the Rural PACE Provider grant program, which provides funding and technical assistance to 15 providers to develop PACE in rural areas. These efforts may help the expansion of PACE in the future (NPA).
|Quality of Health Care Services||marginal||fundamental|
|Level of Equity||system less equitable||system more equitable|
|Cost Efficiency||very low||very high|
PACE evaluations have shown the program reduces hospital and nursing home stays, and improves health status of its enrollees. Low disenrollment rates also show that participants are satisfied with the program (Chatterji et al, 1998).
Petigara, Tanaz and Gerard Anderson