PACE: A Better Model for Elder Care

In my most recent podcast, I talk with Dr. Anthony Zizza, medical director of Element Care, about the Program for All-Inclusive Care for the Elderly (PACE) that provides comprehensive care to older adults. Unlike the piecemeal approach of most health care in the United States, participants in PACE receive one-stop-shopping for all their health needs.

PACE is available to patients who have both Medicare and Medicaid (MassHealth in Massachusetts where Element Care is located) and agree to receive all their care through the PACE program. Medicare and Medicaid pay a fixed amount per participant, which gives the program a financial incentive to keep them healthy and living in the community. As a result, many PACE programs offer nonmedical as well as medical care.

While PACE has existed since 1971, it only expanded from a couple of dozen programs nationwide after 1997 when it became a permanently recognized provider type under Medicare and Medicaid. By 2014, there were 107 PACE programs and by 2023 151 programs serving 68,000 participants in 32 states and the District of Columbia.

Here are some excerpts from our conversation:

Risking Old Age in America: What is PACE?

Dr. Anthony Zizza: PACE stands for the Program of All-Inclusive Care for the Elderly, and it’s a Medicare and Medicaid model for adults 55 and older who need a nursing home level of care, but can still live safely in the community with the right support.

We call the people receiving care “participants” as opposed to “patients” because they really do participate in their care. With PACE, it’s not just a clinic visit and you go home. It’s a full care model. We have 11 different roles deliver high quality, coordinated person-centered care so these older adults can remain in their homes and communities as long as possible.

ROA: How do you make that happen?

Zizza: The system really should wrap around the older adult and not force the older adult and family to chase the system. That’s what traditionally you see for a lot of geriatric patients. We have transportation, physical and occupational therapy, social work, an activities team, physicians, nurse practitioners, physician assistants, nurses, pharmacists, a behavioral health team, dieticians, personal care attendants, an operations team, an adult day health center, robust clinical programs in geriatric primary care, urgent care, palliative care and behavioral health, as well as home-based medical services that we coordinate through our whole team.

We’re also able to take outside-the-box steps. I’ll give you an example: We had a patient who, a participant who had a disease called COPD. It’s a disease that usually longtime smokers get. They have trouble oxygenating their blood and clearing carbon dioxide. So, they are prone to a lot of what we call exacerbations or infections, and they need hospitalization. Many times they go on a ventilator. It’s, it’s a very serious disease, especially as it progresses.

For our patient, we noticed that every summer he would have four or five exacerbations. In the winter, it calmed down. So we bought the patient an air conditioner, and that did the trick.

Once they’re enrolled in our program, we are committed to doing the right thing for them from the moment they enroll until the last breath that they take. We will do everything we can to keep them in the home, including sometimes having 24-hour services in the home.

ROA: How can you afford that level of service?

Zizza: Yes, it’s a lot of money. But these patients would cost the system a lot more if we weren’t involved. We’re preventing emergency room visits, preventing inpatient hospitalizations, and delaying long-term care. All of those things saves the system quite a bit of money.

ROA: Is PACE available nationwide?

Zizza: It could be, but it’s not. Some states do not have PACE programs. Even the states that have them, it’s not as if it’s available in the whole state. It’s quite a convoluted process to establish a PACE program. The organization has to make applications both through CMS as well as through the state Medicaid agency.

The state will grant you certain ZIP codes, which would be your service area, and that has to be approved by CMS. One thing about PACE that I would love to see changed or at least improved, is to reduce the tremendous amount of regulation and red tape that is involved right now programs.

ROA: One of the earlier points you made was that to qualify you have to be clinically eligible as well as financially eligible. What do you mean by clinically eligible?

Zizza: The idea of PACE is to think about it as a nursing home without walls, which means that the participants need to be nursing home eligible. Now, what qualifies you to be nursing home eligible? You need to have a dependence on an ADL or on assistance for an activity of daily living. You may need help with bathing; it could be that you need assistance with medication administration; you may need help with dressing or with making meals. If you need assistance and can’t live alone without it, then you very likely clinically would be eligible for PACE.

You can learn more about PACE by listening to our whole conversation here.

Topics

02:06 Landmark Health House Calls

03:58 Why Landmark Ended

05:20 PACE Explained Basics

06:42 PACE Services and Team

08:04 Outside the Box Care

09:34 Costs and Long Term Care

12:35 Eligibility and Enrollment

16:43 Coverage Areas and Red Tape

18:56 For Profit Growth Debate

20:08 Element Care Mission Stories

23:24 Finding a Local PACE

28:26 Policy and Family Advice

30:43 Criticisms and Risk Adjustment

34:47 Closing Thoughts