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without care

Program of All-Inclusive Care for the Elderly

Program of All-inclusive Care for the Elderly (PACE) programs provide comprehensive health services for individuals age 55 and over who are sufficiently frail to be categorized as "nursing home eligible" by their state's Medicaid program. Services include primary and specialty medical care, nursing, social services, therapies (occupational, physical, speech, recreation, etc), phamaceuticals, day health center services, home care, health-related transportation, minor modification to the home to accommodate disabilities, and anything else the program determines is medically necessary to maximize a member's health.

How PACE works

PACE programs are managed care programs -- they are reimbursed on a fixed per member per month rate (or capitation payment) and, in return for this fixed payment, they are responsible for providing 100% of the health services their members require. Because PACE programs enroll only those individuals who are very frail and incapacitated, they are exactly the patient population for whom prevention and health promotion makes a difference. Most PACE patients have multiple diagnosis, with an average of over 7 diagnoses per member. Among the most common are cardiac problems, diabetes, hypertension, and vascular disease. PACE programs have strong incentives to help keep their members as healthy as possible -- their patients, if left without care, are likely to require a hospital stay, which is very expensive. So PACE programs tend to provide high levels of preventive services, such as very frequent check ups, exercise programs, dietary monitoring, programs to increase strength and balance, etc. PACE programs also focus on "PACE Centers". These Centers tend to have a Day Health Center, physician' offices, nursing, social services and rehabilitation services, along with administrative staff, all in one site. Members may attend centers from rarely to 7 days a week, depending on their care plans. Care planning is done with the member, his or her care team, and appropriate family members. Because most members attend about 2 days per week, staff gets to know the patient extremely well -- their concerns, their moods and their condition. This means that staff of the Centers can quickly determine when a Member does not seem herself on any given day. In that case, the Member will be sent to see the nurse or the physician down the hall, where the clinician can intervene quickly to prevent exacerbation of the problem.

History of PACE

PACE was developed by On Lok Senior Health Services, a not-for-profit organization launched in the early 1970s by concerned citizens in the Chinatown-North Beach area of San Francisco. Through research and demonstration funding from the federal Administration on Aging, On Lok opened an adult day health center in 1972, modeled on the British day hospital program, to provide an alternative for Chinese, Italian and Filipino elderly people in the neighborhood who could no longer manage alone. In 1978, On Lok expanded the model to include complete medical care and social support for the frail elderly and received federal waivers in 1979 that allowed reimbursement from Medicare for all outpatient health and health-related services. In 1980 inpatient services were added, including skilled nursing care and acute hospitalization. The Social Security Act amendments in 1983 provided that On Lok be given authority to test a risk-based financing system involving Medicare, Medicaid and private pay. Major grants from the Robert Wood Johnson Foundation, the John A. Hartford Foundation and the Retirement Research Foundation underwrote research and development activities to support this demonstration. Congress extended On Lok's waivers indefinitely (1985) and provided waivers for the replication of On Lok's model at 10 sites throughout the nation (1986). Foundation support enabled On Lok to provide technical assistance to help new sites develop and to create a cross-site database to track performance. In 1990 the first replication sites received Medicare and Medicaid waivers as demonstration programs and the model became known as the "Program of All-inclusive Care for the Elderly" or PACE. The Balanced Budget Act of 1997 (P.L. 101-33, Section 4801-4803) established PACE as a permanent part of the Medicare program and an option under state Medicaid programs. Existing PACE demonstration programs became permanent PACE providers by 2003. The Deficit Reduction Act (DRA) of 2005 authorized a Rural PACE initiative and in 2006 the Center for Medicare and Medicaid Services (CMS) announced 15 rural PACE grantees.

As of March 2007, 38 PACE and 8 Pre-PACE programs operate in 23 states. The largest of these has more than 2,000 frail elderly enrollees, but most serve a few hundred. More information about PACE programs can be obtained from the National PACE Association, based in Virginia.

Comprehensvie Care Management or CCM, is a not for profit company that uses the PACE program. It serves the New York metropolitan area, including Westchester County and the New York City boroughs of The Bronx, Manhattan, Brooklyn and Queens. In the early 1980's Beth Abraham Health Services, a not-for-profit nursing facility, was the first organization in the country to try and replicate a program in San Francisco designed specifically to help frail elderly people avoid having to live in nursing facilities. It called its program CCM, or Comprehensive Care Management. CCM, also a not-for-profit corporation, combines an adult day center with medical care and home care and a fixed per member per month payment (called a capitation payment). Each patient has an interdisciplinary team with a physician, nurse and social worker that works with the individual and his or her family in care planning and monitoring. Primary services are provided in an integrated care care setting with physician, nurse, social workers and therapists on site (the PACE Center). The resident may attend the PACE Center anywhere from rarely to seven days a week, depending on their care plan.

The Cherokee Nation Comprehensive Care Agency's Cherokee Elder Care (CEC) is one of the first rural PACE programs and the first tribally sponsored programs in the country. Its first facility is due to open mid-2008, in Tahlequah, Oklahoma.

In 1996 Upham's Corner Health Committee, Inc. based in Dorchester, MA opened its first PACE Program, Upham's Elder Service Plan (UESP), in Dorchester, Massachusetts. In April 2008, after 8 years of searching the neighborhoods of Boston, UESP opened its second PACE Center in Roxbury, MA. The second site will expand the total enrollment of the program to approximately 300 participants. The new Roxbury site, located on Dearborn street features many state of the art amenities that increase the service availability to the participants it serves. The site includes a state of the art rehabilitation room, a large nursing treatment room, and two large day rooms for participants to socialize and receive services.

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