Home Health Care News: Despite Formidable Challenges, PACE Leaders Keep Expansion Dreams Alive

By Joyce Famakinwa

The Program of All-Inclusive Care for the Elderly (PACE) concept has gained significant business and policy momentum over the past several months, with recent research also highlighting just how successful programs were at avoiding COVID-19 deaths compared to other care settings.

Despite that traction and the model’s clear benefits, PACE still faces a long list of formidable growth barriers.

An alternative to nursing homes, PACE is a Medicare and Medicaid program that helps keep people in their communities. Oftentimes, programs are run out of community-based centers with the support of in-home care providers and their staff.

“Embedded in this model is that the PACE program also addresses the social determinants of health for the enrollees and wraps around this care with a very comprehensive interdisciplinary care team,” Jade Gong, founder and principal of consulting firm Jade Gong & Associates, told Home Health Care News.

At any particular time, 95% of PACE enrollees are living in the community, with about 5% in nursing homes, according to Robert Greenwood, senior vice president of public affairs at the National PACE Association.

“This is pretty remarkable, given that you have to be eligible for nursing home care before you can even enroll in PACE,” he told HHCN.

Based in Alexandria, Virginia, the National PACE Association is an industry advocacy group that focuses on federal and state policies to support the financial viability of the PACE model.

Broadly, the majority of PACE participants are eligible for both Medicare and Medicaid. PACE operators receive a set monthly payment for each participant. Typically, PACE is both payer and provider.

“Having a capitated payment really helps the PACE model because we’re able to emphasize providing primary and preventive care over the things that are really expensive, which are emergency room visits, hospital visits or permanent placement in a nursing home,” Greenwood said.

While the PACE model has been attracting interest over the past few years, the COVID-19 emergency played a major role in ramping up this attention, according to Gong.

“The model just performs so well under COVID,” she said. “There are many different kinds of providers — nonprofit, for-profit, housing — that are interested in PACE or relationships with PACE programs.”

If one provider exemplifies the performance success the model saw amid the public health emergency, it’s WelbeHealth, a Menlo Park, California-based operator of PACE programs.

Overall, WelbeHealth and the PACE community had lower death rates than their nursing homes counterparts, research has found.

In fact, the national PACE COVID-19 death rate was 3.8%, compared to 11.8% in nursing homes. WelbeHealth’s COVID-19 death rate was 2.4%, according to a recent case study conducted by UC Berkeley.

For context, WelbeHealth serves LA and Central Valley, which have both been COVID-19 hotspots at times.

“These were places where crematoriums listed their pollution caps because they had too many bodies piling up,” Si France, founder and CEO of WelbeHealth, told HHCN. “This is where paramedics were asked to start rationing care. The hospitals were full, and they had to fill up their parking lot pop-up units. That was the nightmare context where we had these dramatically lower death rates.”

Over the years, WelbeHealth has seen growth as the organization aimed to serve underserved markets in California. The company added a Fresno program in late 2020 and will serve about 1,000 participants by the end of the year.

“We ranked California cities by highest unmet need, and started working on serving them, in order, beginning with Stockton and Pasadena in 2019, then Long Beach in 2020,” France said. “None of these communities had any PACE services despite having a high need. You had no access to this program that increases quality of life and length of life.”

France noted that PACE enrollees experience an 80% reduction in depression and generally have a higher life satisfaction. They also tend to live longer under the comprehensive and interdisciplinary care model.

Despite strong outcomes from many PACE providers, such as WelbeHealth, there is still room for expansion.

In total, there are 140 PACE organizations operating 272 PACE centers in 30 states, serving over 56,000 participants, according to the National PACE Association.

One of the major barriers to furthering PACE expansion is how high the cost of entry can be for new operators.

“When an organization wants to look at developing a PACE program, it’s not just building the center, hiring the staff, having the right information systems, and leasing or buying the vans to provide transportation,” Greenwood said. “Part of the startup costs is operating in those initial months when you don’t have a big enough enrollment to bring in the revenue that really covers all your expenses.”

Another roadblock is the PACE application process, which requires the state to develop a rate-setting methodology for anyone who’s a Medicaid eligible PACE enrollee. States must also agree to take on certain oversight responsibilities.

“One of the things that really stops a provider from being able to develop PACE is the willingness of the state they’re operating in to support that development,” Greenwood said.

In an effort to drive PACE expansion, Sen. Bob Casey, a Democrat from Pennsylvania and chairman of the Senate Special Committee on Aging, introduced the “PACE Plus Act” in April.

The legislation has received a warm reception from industry insiders for being comprehensive and attempting to cut through red tape.

“I have some sense of optimism that we’re going to get some real traction on the bill this year,” Gong said. “I have talked to some of the senators in states where I have clients, and there’s tremendous interest in seeing PACE expansion.”

If passed, the PACE Plus Act would make room for the creation of new PACE programs and the expansion of current ones through federal grants. The legislation also encourages non-PACE states to take up the model by providing incentives.

Additionally, the legislation would lessen the bureaucratic burden that growing PACE programs face while also providing technical assistance resources.

Another bright spot has been various states’ willingness to consider the PACE model, according to Greenwood.

“States have been looking more closely at how they want to provide long-term care supports and services in the future,” he said. “They’re looking at what else they can do beyond offering nursing home residential care. I think they’ve become a lot more open to supporting PACE as a way to provide more healthy community-based services.”

UC Berkeley Study Reveals WelbeHealth’s Rapid Adaptation To COVID-19 Eldercare Yielded Exceptional Results And Saved Lives

As policy momentum grows toward home and community-based services, study recommends that policy choices focus on the Program of All-Inclusive Care for the Elderly (PACE), and it’s 45-year track record of success in serving the most complex elderly patients.

SILICON VALLEY, Calif., July 14, 2021 — A new study from UC Berkeley’s Berkeley Roundtable on the International Economy (BRIE) features WelbeHealth in a case study illustrating how this California eldercare PACE provider responded early and decisively to the COVID-19 crisis with exceptional results.

“By rapidly transforming its care model, WelbeHealth had exceptional results: as COVID-19 cases rose across the country — and in particular within nursing home populations — WelbeHealth did not have a single COVID-19 death during the first 8 months of the pandemic. The first WelbeHealth loss from COVID-19 occurred on November 21, 2020 and 10 WelbeHealth participants died of COVID-19 since the beginning of the pandemic.”

-UC Berkeley

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Welbehealth: Case Study of Adapting PACE Under COVID-19

Key findings:

  • WelbeHealth and the PACE community overall had lower death rates than nursing homes; the national PACE COVID-19 death rate was 3.8%, nearly one-third the 11.8% death rate in nursing homes. WelbeHealth calculated a death rate of 2.4%.
  • WelbeHealth acted early and decisively to minimize exposure with an Incident Command response strategy, dispersing tablets for telehealth visits, PPE, thermometers, food, medication, and other essentials into participants’ homes, and providing nearly all care remotely, which proved effective.
  • PACE’s capitated payment model moves the risk from payor to care provider, aligning incentives and encouraging innovation and efficiency in keeping patients well.
  • Technology provided an important amplification to PACE’s model of care — it allowed for regular check-ins and informed decision-making on care needs. However, the social aspect of the PACE day center cannot be replaced by technology, and it is clear that in-person visits are vital.
  • With America’s senior citizen population set to double by 2040, the demand for long-term care will skyrocket. The pandemic underscored that work must begin now to meet the needs of present and future vulnerable elders.
  • Existing home and community-based services (HCBS) such as PACE demonstrated profound success during the pandemic leading to fresh momentum among policymakers to expand these options further.

PACE’s person-to-person, fully integrated approach maintains the participant’s highest level of independence and quality of life[i]; PACE participants experience an 80% drop in rates of depression after joining.[ii] At a time when America is searching for a better way forward in eldercare, PACE is a proven approach for this vulnerable group.

 

“While PACE has a 45-year track record of success, it remains optional in Medicaid while nursing home benefits are required — it’s time for every vulnerable elder in the country to have access to this gold standard of long-term care,” said Elizabeth Carty, Chief Regulatory Affairs Officer of WelbeHealth.

 

Many PACE participants reside in medically underserved areas like San Joaquin County, California, where WelbeHealth’s creative problem-solving and speed to action kept seniors safe in their homes when resources for the elderly were relatively scarce.

 

“As other healthcare organizations were assessing the potential impact and spread of the pandemic, the WelbeHealth team had already taken its crisis response to the next level, ” said Amy Shin, former CEO of Health Plan of San Joaquin. “I was impressed with how nimbly this team charted out a plan not only to keep seniors safe and vaccinated but to vaccinate the community as well. This study’s findings should alert legislators that this style of home and community-based services is the ideal model of care for frail seniors.”

 

What is PACE?
PACE (Program of All-Inclusive Care for the Elderly) serves low-income seniors who meet their state requirement for nursing home level care allowing them to live independently in their own homes and communities while receiving fully coordinated medical and dental care, physical and occupational therapy, transportation, meals, day programs, home care assistance and more, managed by an 11-person integrated care team. The “one-stop-shop” PACE day centers are the hub of the program, offering seniors a pleasant place to receive care, socialize and enjoy meals within a state-of-the-art facility.

About WelbeHealth
WelbeHealth is a physician-led healthcare organization that provides seniors with high-quality, compassionate care so they can live in their own homes and communities rather than a nursing home. To accomplish this, WelbeHealth uses the PACE (Program of All-Inclusive Care for the Elderly) model. WelbeHealth currently operates four programs in the Stockton/Modesto, Pasadena/Burbank, Long Beach, and Fresno communities of California.


[i] Center for Consumer Engagement in Health Innovation, “Care That Works: Program for All-inclusive Care for the Elderly.” https://www.healthinnovation.org/resources/publications/care-that-works-pace

[ii] National PACE Association, “COVID Data Demonstrates That the PACE Model Is Safer Than Nursing Home Care.” https://www.npaonline.org/about-npa/press-releases/covid-data-demonstrates-pace-model-safer-nursing-home-care

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TIME MAGAZINE: COVID-19 Exposed the Faults in America’s Elder Care System. This Is Our Best Shot to Fix Them

June 15, 2021 (Time Magazine) – When COVID-19 hit the United States, nursing homes in Washington State took the first hit, producing deadly outcomes for older adults. Conditions within long-term care facilities enabled a harrowing spread of any pandemic, let alone a novel coronavirus. Compounding on this, leaders within institutional care were slow to respond when it arrived.

The plight of residents in long-term care facilities across the United States is detailed in a report by Abigail Abrams from Time Magazine. It begins with individuals living at Life Care Center in Kirkland, Washington, in late February 2020 where COVID-19 killed dozens in just a few weeks.

The shocking death rate created a sense of panic and by early March the families of those living within Life Care Center held a press conference appealing to the public on behalf of their loved ones.

“Our families are dying. We don’t know what to do. Our calls for help aren’t working,” said Kevin Connolly, whose father-in-law lived in the facility. “We have limited resources to battle this disease, and I think somebody somewhere decided that this population of people wasn’t worth wasting resources on.”

Nursing homes vs infection

Many nursing home residents live in shared rooms and rely on staff who tend to numerous patients and who often work at various other facilities. The industry’s low pay and long hours make for high turnover. These characteristics can create a lack of consistency in controlling the spread of infection.

The nursing home industry is losing occupancy rates, workers, and money. The long-term care industry could lose an estimated $94 billion between 2020-2021 due to the costs involved in both fighting the pandemic and losing occupancy, according to The American Health Care Association and National Center for Assisted Living (AHCA/NCAL).

America is aging rapidly. According to the Census Bureau, around 10,000 Americans turn 65 every day. Most people want to age at home rather than in an institution. Still, people who qualify for Medicaid and Medicare have little to no choice in where they receive long-term care after reaching old age. Governments in many states mandate that they enter long-term care facilities even when home-based care services are available.

In many cases, when a person does not qualify for government-funded care or chooses to avoid mandated care in a nursing home, a family member must often forfeit a job to take on the responsibility of caregiving. And if no one in the older adult’s circle of support can provide that care, paid home based care is challenging to find due to worker shortages. Many workers are leaving the historically low-wage industry, according to the Bureau of Labor Statistics.

Policy helps pave the way to home and community-based care.

Policy momentum is growing toward home and community-based care for the elderly across the nation. One home-based care program available to Medicaid/Medicare recipients has a 45-year proven track record of success and operates in more than 31 states. PACE (Programs of All-Inclusive Care for the Elderly) saves the government money while offering a high-touch, team-based approach to eldercare for people 55 years or older who qualify for nursing home level care.   It receives a payment per participant to provide medical care and dental care, day center programs, meals, home health aides, and many other services to keep seniors safe and living in their own homes and communities. PACE aims to keep this elderly population out of hospitals and nursing homes while incentivizing a flexible, creative, team-based approach to care. On average, states pay PACE programs 13% less than the cost of other Medicaid services.

“The nature of payment provides significant flexibility, as well as really strong incentives for PACE organizations to really proactively monitor and get out in front and address existing and emerging health needs,” says Shawn Bloom, president, and CEO of the National PACE Association.

Data collected during the pandemic show that seniors enrolled in PACE contracted COVD-19 at just one-third the rate of those in nursing homes, according to the National PACE Association.

The push for greater government funding for programs like PACE is growing. President Biden’s proposal to spend $400 billion on home care over the next 4 years could pave the way toward boosting access to more Americans. And proposed legislation in California, Assembly BILL (AB) 540, would allow eligible seniors to be automatically informed about PACE right along with other Medicaid and Medicare options.

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mHealthIntelligence: California Provider Sees Telehealth as an Integral Part of PACE Programs

WelbeHealth President Matt Patterson says COVID-19 has taught the industry a good lesson on how to use telehealth, and it should be a permanent part of the senior care service.

By Eric Wicklund

 – A California-based healthcare provider is integrating telehealth into its PACE programs, saying the connected health platform improves its ability to provide value-based care for seniors in their own homes.

While the focus of PACE programs has been on in-person care, the coronavirus pandemic prompted many to shift to connected health to maintain contact with their patients. For WelbeHealth, that meant partnering with Grandpad to equip patients with senior-friendly mHealth tablets that allow them to connect with caregivers on-demand and access health and wellness resources online.

“COVID-19 introduced the need for us to pivot to telehealth,” says WelbeHealth President Matt Patterson. “And in the process, we have saved lives.”

WelbeHealth is one of hundreds of providers focused on the senior care market, many of which participate in the Centers for Medicare & Medicaid Services’ Program of All-inclusive Care for the Elderly (PACE) program. Developed by CMS roughly 30 years ago as a capitated model of care for dual-eligible beneficiaries (ninety percent are dual-eligible), it provides all necessary medical care, therapies, long-term care and services, meals, socialization, transportation, day center services, and activities.

There are currently 135 PACE programs in 31 states, enrolling between 50 and 3,000 patients, for a total of more than 54,000 seniors served. The programs are based in a care center and feature an interdisciplinary care team (IDT) of primary care physicians, nurses, therapists, social workers, dieticians, home care professionals, and others and offers a variety of services on-site and in the home.

PACE programs have traditionally shied away from telehealth, but COVID-19 changed that line of thinking. Now Patterson and his team are at the forefront of a new wave of care providers who want to make telehealth an integral part of the program.

“It’s an exciting opportunity to extend the reach of PACE (and) do more to improve and enrich the lives of our participants,” says Patterson, a former naval surgeon who served as president of digital health pioneer AirStrip before moving into the senior care space.

Telehealth gives PACE programs with WelbeHealth’s the ability to be there for seniors at any time, and to address issues that might not be addressed during in-person visits. That’s important at a time when, mostly due to COVID-19 restrictions, seniors are experiencing high rates of depression, anxiety, stress and substance abuse.

That point has been proven in the Grandpad project. According to a case study, seniors in the WelbeHealth program logged nearly 34,000 hours on the tablets – using both synchronous and asynchronous services – between March of 2020 and March of 2021, including more than 1,500 hours accessing mental health treatment. They also used the tablets to access medical care and exercises aimed at treating cognitive decline.

Patterson says emergency measures adopted by both state and federal governments during the COVID-19 public health emergency have enabled PACE programs to use telehealth more freely. He and his company have been lobbying state officials to make those freedoms permanent.

On the federal level, a bill introduced in March and now before Congress would ensure permanent coverage for audio-only telehealth services for Medicare Advantage and PACE programs, giving providers like WelbeHealth the freedom to incorporate phone calls and non-video telehealth platforms into care plans.

The benefits of connected care are numerous. On-demand access to care providers means seniors can go about their day knowing there’s someone always available should an emergency occur. They have instant access to health and wellness resources that go beyond what they’re getting when the nurse comes by for a visit. They can also collaborate more often on medication management, keep track of daily vital signs, or just talk to someone if they’re lonely or depressed.

Patterson says the pandemic is giving WelbeHealth and others the time to prove the value of connected health and to gather data and experiences to support permanent coverage.

That will be important. CMS has traditionally been very reluctant to expand telehealth coverage and has long argued that it needs evidence that these tools and platforms improve clinical outcomes and reduce wasteful expenses and unnecessary treatments. In short, they want proof.

“PACE is an ideal model for integrating high-touch and virtual care,” Patterson counters. And he wants to do more of that.

“Telehealth is definitely not a replacement (for in-person care), but it gives us more tools, and we want to use these tools for what our participants desire,” he says. “As an organization, we only do well when our participants do well. And they’re doing well.”

 

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