Mark A. Newbrough, MD
Medical Director, Blue Ridge PACE
Assoc. Prof., Section Head for Geriatrics
University of Virginia
Disclosure
 Blue Ridge PACE is a new program serving
Charlottesville, and surrounding counties of
Albemarle, Fluvanna, Louisa, Greene, and Nelson
 I am medical director for Blue Ridge PACE
 UVA, JABA, and Riverside Health Systems are
partners in Blue Ridge PACE
Objectives
 Describe the key aspects of the PACE model of
care
 Describe the proven benefits of the PACE model of
care
 Explain the basic components of how the PACE
Interdisciplinary Team interacts with other
providers, including inpatient providers to
comprehensively meet the needs of frail older
adults
Mr. Jones
 Mr. Jones is an 87 year old patient that has seen you in your
practice for the past 8 years. His 54 year old daughter
provides 24 hour care for him in her home. She has had to
quit her job, and her marriage is threatened by the
demands of caregiving. She is no longer able to take her
father out to church, and despite the fact that you have
worked tirelessly with the social worker to provide
additional support for the patient and his family, she fears
that she may have to place her father in a nursing home.
She asks if you know anything about the new PACE
program here in town.
What is PACE?
 According to CMS website:
 Medicare program for older adults and people over age
55 living with disabilities
 Provides community-based care and services to people
who otherwise need nursing home level of care
 Created to provide participants, families, caregivers, and
health professionals flexibility to meet the health needs
of participants and help them to continue living in the
community
 Care is provided and coordinated by an interdisciplinary
team (IDT) of health professionals
CMS “Quick Facts” (cont.)
 PACE provides all the care and services covered by
Medicare and Medicaid, as authorized by the IDT, “as well
as additional medically-necessary care and services not
covered by Medicare and Medicaid”.
 True “participant centered care”
 PACE programs are provider sponsored health plans: “This
means your PACE doctor and other care providers are also
the people who work with you to make decisions about
your care.”
 Preventive care is covered and encouraged
PACE Services include:
 Primary care (including
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physician and nursing
care)
Hospital Care
Medical Specialty Services
Prescription Drugs
Nursing Home Care
Emergency Services
Home Care
Physical Therapy
Occupational Therapy
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Adult Day Care
Recreational Therapy
Meals
Dentistry
Nutritional Counseling
Social Services
Laboratory / X-ray services
Social Work Counseling
Transportation
Who is Eligible for PACE?
 Age 55 and older
 Long term nursing care eligible (but only 7% of
PACE participants nationally actually live in
nursing homes)
 Live in a PACE service area
 Able to live safely in the community at the time of
enrollment in PACE
Long Term Nursing Eligibility
 UAI: Uniform Assessment Instrument
 Criteria:
1.
Dependent in 2-4 ADL’s
• PLUS semi-dependent OR dependent in behavior AND orientation
• PLUS semi-dependent in joint motion OR medication
administration
2. Dependent in 5-7 ADL’s
• PLUS dependent in mobility
3. Semi-dependent in 2-7 ADL’s
• PLUS dependent in mobility
• PLUS dependent in behavior AND orientation
History of PACE (NPA website)
On Lok (Cantonese for “peaceful, happy abode”)
1971: Outlined as comprehensive system of care based on
the British day hospital model
1973: Opens one of the nation’s first adult centers in
San Francisco
1974: Begins receiving Medicaid reimbursement for adult
cay health services
PACE History (cont.)
1975: Adds social day care center and includes in-home care,
home-delivered meals and housing assistance
program
1979: 4 year Dept. of HHS grant to develop a consolidated
model of delivering care to person with long term care
needs
1983: Develops new financing system that pays a fixed per
member per month payment
1986: Federal legislation extends new financing system and
allows 10 additional organizations to replicate mode
PACE History (cont.)
1986: Federal legislation extends new financing system and
allows 10 additional organizations to replicate model
1987: Robert Wood Johnson support
1990: First PACE programs received Medicare and Medicaid
waivers to operate the program
1997: Balance Budget Act of 1997 establishes PACE model as
permanently recognized provider type under
Medicare and Medicaid programs
1997 Review (1)
 Findings:
 In 1995, PACE fully operational in 11 cities, nine states
 Average enrollee: 80 years old, 7.8 medical conditions,
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an 2.7 dependencies in Activities of Daily Living
55% with urinary incontinence
39% living alone, and 14% with no informal support
Reductions in use of institutional care w/ controlled
utilization of medical services
Cost savings to Medicare and Medicaid
PACE IDT Function is Critical (3)
 Findings:
 Teams must include: primary care physician, nurse,
social worker, PT, OT, recreational therapy, dieticians,
PACE day center coordinator, home care coordinators,
personal care attendants, and drivers
 Prior studies had shown that patients cared for by teams
have better survival, functional, and cognitive outcomes,
as well as lower institutionalization rates
 This study looked at PACE teams for variation
Team Function (cont.)
 Attendance at team meetings varies according to
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participant being discussed
Team meetings typically run by a facilitator
Validated team performance tool compared to rates of
urinary incontinence and ADL function at 3 & 12 months
Statistically significant improvement in ADL’s at 3
months an 12 months with higher functioning teams,
and urinary incontinence at 12 months
No association with mortality rates
Note: sites with higher nursing FTE had lower mortality
but not better ADL or UI outcomes
2004 & 2009 Health Policy Reviews
 Findings:
 Lower rates of nursing home admission, shorter hospital
stays, lower mortality rates, and better self-reported
health
 Costs for PACE enrollees are 16-38% lower than
Medicare fee-for-service costs for a frail elderly
population
 5-15% lower costs than for comparable Medicaid
beneficiaries
 More likely to die at home
Health Policy articles (cont.)
 Challenges: Cost and Model structure
 Many older adults not keen on adult day center
 Reluctance to “change doctor”
 Expensive start up costs, and costly to expand
 For profit providers have not entered market
 Challenges with state support: concern over Medicaid
budgets
 Unaffordable for middle income individuals
2013 Update: Medicaid costs (5)
 Waiver cohort least impaired to NH most impaired
 PACE cohort was a blend between waiver and NH
when looking at burden of illness
 Expected Medicaid annual costs for PACE type
participants in alternative long-term care was
$36,620
 Actual Medicaid capitation to PACE was $27, 648
(28% below the lower limit of predicted fee-forservice payments)
PACE in Virginia
 Rapid growth since mid-2000’s in Virginia
 13 Centers in: Stone Gap, Newport News, Cedar
Bluff, Richmond, Fairfax, Hampton, Roanoke,
Lynchburg, Virginia Beach, Portsmouth, Farmville,
and Petersburg
 Blue Ridge PACE is the 14th center in Virginia, our
program opened March 1, 2014
Blue Ridge PACE
 Non-profit corporation formed by three partners:
 UVA Health Systems
 Jefferson Area Board on Aging (JABA)
 Riverside Health Systems
 Located at:
1335 Carlton Ave.
Charlottesville, VA 22902
434-529-1300
www.blueridgepace.org
Mr. Jones Revisited
 BRP participant for 18 months, he has had three
comprehensive team assessments, the last one 3
weeks ago
 Receives 14 hrs. of home care weekly
 Visits PACE center 5 days per week
 Participates in activities at the center
 Daughter has returned to work, relationships have
stabilized
Mr. Jones Becomes Ill
 Both his home aide and driver notice he appears ill
one morning
 After a short discussion in the morning IDT
meeting, he is seen by nurse and doctor in PACE
clinic same day, with normal WBC and negative
CXR done, but fever and cough present
 Goals of care reviewed with family, and decision
made to try oral antibiotics and observe closely
 Antibiotics started
Mr. Jones’ Follow-up
 He is seen again the next day in the PACE clinic
 Tolerating antibiotics, food, and water, no
noticeable deterioration from previous day
 That night becomes acutely short of breath,
becomes frightened, and so does his family
 They contact PACE nurse on call, who also
consults with physician
 Due to rural home location, and acuteness of SOB,
decision made to send to ER
ER Stay
 Labs and CXR confirm diagnosis of pneumonia, but
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breathing calms down with O2 supplementation
Family is unsure of next steps, and not sure they can
manage patient at home
Hospital team and PACE physician discuss case, and
decide to admit Mr. Jones
Complete medication list and summary provided
The next day, both the Mr. Jones nurse and the
physician check on him and assist with care planning
Next Day
 PACE team meets with family, and proposes plan
of care:
 Discharge from hospital to SNF for course of IV
antibiotics and observation (no 3 day stay required)
 Restorative therapies will assess him at SNF, and
determine need for therapy
 Additional discussions with family depending on clinical
course
 Discharge from SNF to home after only 3 days, with
home evaluation and clinic evaluation within 24 hours
of discharge
PACE Summary
 Comprehensive model of medical and social care
 Team based, participant centered
 Focus on keeping people in their home
 Provide needed care at lowest cost level of care
 Increased flexibility compared to usual Medicare /
Medicaid fee-for-service care
 A community based partner who can help care for
our oldest and most frail patients, and will help
care for them wherever they may be
References
Eng, Catherine; Pedulla, James; Eleazer, Paul G.; McCann,
Robert; and Fox, Norris. “Program of All-inclusive Care for the
Elderly (PACE): An Innovative Model of Integrated Geriatric
Care and Financing”, JAGS Vol. 45, No. 2, Feb 1997, pp. 223-232,
244
2. Gross, Diane L., et al, “The Growing Pains of Integrated Health
Care for the Elderly: Lessons from the Expansion of PACE, The
Milbank Quarterly, 2004, Vol. 82, No. 2, pp. 257-82
3. Mukamel, Dana B., et al, “Team Performance and RiskAdjusted Health Outcomes in the Program of All-Inclusive
Care for the Elderly (PACE), The Gerontologist, 2006, Vol 46,
No. 2, pp. 227-237
1.
References (cont.)
4. Petigara, Tanaz and Gerard Anderson. “Program of All-
Inclusive Care for the Elderly”. Health Policy Monitor,
April 2009
http://www.hpm.org/en/Downloads/Health_Policy_
Developments.html
5. Wieland, Darryl, et al, “Does Medicaid Pay More to a
Program of All-Inclusive Care for the Elderly (PACE) Than
for Fee-for-Service Long-term Care?, J of Gerontology, A
Biol Sci Med Sci, 2013 January: 68(1): 47-55