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Patients and staff benefit from the collaborative approach of the PACE program at On Lok Senior Health Services in San Francisco (left to right): translator Sabrina Cheng, MSW; Pat Thornton, RN, clinic nurse practitioner; program participant Jie Bing Huang; and Pauline Chong, geriatric assistant

What if you could take all the services and care that a nursing home provides, and provide them at home?

Ask elders if they’re willing to go to a nursing home, and an estimated 30% will say they’re unwilling — and another 30% may say they’d rather die, according to an article in the 1997 issue of the Journal of the American Geriatrics Society. Even for those who are willing, a bed is not always available in their preferred facility — or any facility at all.

Although some of the fears about nursing home care are unfounded, it’s no surprise that most of us would rather stay at home than live in an institution, no matter how attractive and accommodating it is. Alternatives such as assisted living facilities and senior housing can’t — or won’t — provide services for elders who wander, are incontinent, or have complex health needs. But how else can frail elders, particularly those with physical and mental limitations, navigate the maze of medical services, even with the assistance of family?

The goal of PACE — the Program of All-inclusive Care for the Elderly — is to do just that. Rather than struggling with the complexities of payment and providers, PACE programs provide a one-stop shop of preventive, primary, acute, and long-term services for their enrolled members. Once a person is enrolled in the program, PACE takes on responsibility for managing the health, mental, and psychosocial needs of each participant. And nurses are a key component of their care.

Special connection

“For me, this is the essence of nursing,” says Sheri Filak-Taylor, BSN, center director of Total Longterm Care, Denver. “I’ve been an RN since 1983 and worked in critical care, the ED, ICU, and home care, and this is the first job where I feel I make a difference in someone’s life, day to day, at whatever stage they are physically or cognitively. We really bring joy to the later years.”

Being there for the long term is what is most satisfying for many nurses who work with PACE patients. “The main satisfaction is we care for people over extended time and get to know their special needs,” says Pat Thornton, RN, MSN, GNP-C, clinic nurse practitioner at On Lok Senior Health Services, San Francisco. Thornton, a former Peace Corps teacher, also was a physical rehabilitation nurse for 13 years and worked with elders and at an AIDS hospice. “I wanted to do primary care nursing and long-term care,” she says. “I went back to school to become a nurse practitioner. I knew about On Lok, and was lucky a job was available here. It allows us to manage elders with functional and medical problems, in the community, through a multidisciplinary approach. We can provide continuity and stable care. Instead of seeing elders with multiple medical problems, we see them as individual human beings.”

Nurses also feel they can make a difference in their patients’ lives in a direct way through the PACE program. The program, they say, allows for strong bonds between patient and nurse. “We bond strongly with participants, and that really means a lot to staff,” says Lynn Kefgen, BSN, director of clinical and nursing operations, Providence ElderPlace, Seattle. “We become like family, and we know these participants inside out, their needs and joys.” Kefgen, who worked in med/surg and ICU before spending 12 years as a home health nurse and manager, was the first nurse to join the program, and put the clinic together from scratch.

“I heard about it while I was in home health, and it seemed too good to be true,” she says. “There’s nothing like it. We do follow federal guidelines, but it’s rewarding because we don’t have to follow traditional rules. We use funds in the best ways for individual participants.”

Tending to their needs

“Our philosophy is based on the belief that we best serve chronically ill elders and their families, within the community when possible, by providing a seamless continuum of care that respects them as individuals,” says Jennie Chin Hansen, RN, executive director of the On Lok PACE program. “Rather than looking at people as patients who passively receive care, we refer to them as participants because they are actively engaged in the program.”

The extent of care and services is comprehensive and extensive, Hansen says. Working from a clinic base open five or six days per week, PACE offers participants medical care from a clinic provider (a physician or, in some states, a nurse practitioner) who has a limited caseload, all necessary prescription drugs and medical equipment, and specialist services such as audiology, dentistry, optometry, speech, and podiatry, including routine and preventive care. Through an adult day care program, participants have a place to gather, socialize, and enjoy recreational activities, while receiving nursing care and monitoring, meals, nutritional counseling, social services, personal care including bathing and foot care, and physical and occupational therapy. Transportation is provided. Some PACE programs also include their own housing component for participants.

The social component is important to participants, particularly those who otherwise have few opportunities for interaction, and limited or no family contact. At a time when death has ended many relationships, friendships still can flourish. So does romance; in Denver and at other PACE programs, participants have fallen in love and married.

If there is a change in functional or mental status, participants can receive a same-day evaluation by a nurse or physician.

At their own homes, as needed, PACE participants also can receive personal, home health, and respite care. When necessary, the PACE program also covers hospital and nursing home care. PACE programs also have found and furnished apartments for homeless participants. When participants need 24-hour care, PACE has complied, sometimes by providing live-in staff (on shifts) in cluster apartments that allow several staff and participants to live side by side in multibedroom apartments.