Setting the PACE
Alternative senior care programs keep up with the needs of the nation's elderly, providing participants with a sense of community and indepenence

By Janet Wells
December 12, 2002

"We changed the financing and delivery system to focus on the patient, or as we say, participant. It's about the active engagement of a person, rather than having them be a passive recipient of patient care," said Hansen, who has worked at On Lok for 22 years and serves on the national board of the American Association of Retired Persons. "People still want to have independence, as much of their life in the community as possible, and stay connected to traditional bonds."

Where everybody knows…

PACE also offers services not usually covered under Medicare and Medicaid, such as preventive care, end-of-life care, recreation, therapeutic activity, meals, transportation, house cleaning and repairs and, as Hansen said, "just taking people over to the ballgame or the symphony."

"It's not just a medical or physical care system," she said. "It encompasses people's well-being and mental health."

On Lok, the largest of the country's 25 PACE programs, has six centers in San Francisco, as well as a new facility in Fremont, Calif. The centers reflect the Bay Area's multicultural population, with many different languages and immigrant populations represented. About 30 RNs and LVNs are on staff, along with NPs, physicians, physical therapists, home health and recreational aides.

On Lok's center on Bush Street serves 150 participants. It offers a full medical clinic, recreation and social programs, rehabilitation and physical therapy, hot meal service, as well as residential apartments for those participants who are no longer able to live at home. On the roof is a flower and vegetable garden, where participants tend lettuce, sugar peas, spinach, cilantro and bok choy. One wall has a small burbling koi fishpond, and the raised wood beds are decorated with colorful tiles hand-painted by participants. Down on the street, On Lok vans pull up to transport participants to and from the center, as well as deliver meals and provide services to seniors who cannot leave home.

"It's kind of like participants have a Cheers bar to go to," Hansen said. "We know about their idiosyncrasies, what they like to eat, who they like to sit next to."

The On Lok program started in the early 1970s, when the Chinatown-North Beach community of San Francisco saw that nursing homes were infeasible both financially and culturally for immigrant families and their elders.

"The culture is very much into taking care of your own," said Arline Hong Siu, On Lok's marketing project manager, of the Chinese population. "There is a huge respect for the elderly population. We are taught from a young age to make sure that we are going to be taking care of parents and grandparents when they grow older and not put them into a nursing home situation. Of course, that's not always possible, but that's the goal."

Based on the British day hospital model, On Lok opened one of the nation's first adult day centers in 1973, and a year later began receiving Medicaid reimbursement for its services. In the mid-1980s, other organizations began replicating On Lok's model and, in 1997, federal legislation established the PACE model as a permanently recognized provider under Medicare and Medicaid programs. Now, 36 PACE centers (11, however, are pre-PACE sites and are not yet receiving full federal funding) in 19 states serve more than 8,000 participants.

To qualify for a PACE program, participants must be at least 55 years old (the average participant, however, is 80 years old), live in the program's immediate service area and be certified by their state to need nursing home care. Almost 90 percent of participants qualify for full financial aid, with Medicaid and Medicare paying a capitated rate that averages about $3,750 a month per participant nationally.

At On Lok's Bush Street clinic on a recent Thursday morning, Adrienne Low, ANP, examined participant Johnnie Ross. The 79-year-old Louisiana native, dressed in a white T-shirt, denim jacket and blue sweat pants, had come downstairs from his residential apartment on the fourth floor to have a leg wound checked.

When Low saw that Ross was carrying sheet music and a worn book of gospel hymns, she ducked out of the room to retrieve a tape of a piano concert that Ross sang in. Low popped the tape in a portable player and examined Ross, who hummed along to his own soulful voice in the background.

Low oversees primary care services, in conjunction with clinic physicians. She usually starts her morning by 8 a.m., meeting with the clinic's RNs-who act as case managers-to discuss acute patients and make treatment decisions.

"The nice thing about working here is the multiculturalism and the collaborative practice," Low said. "It's wonderful to work with a whole team where, with the physicians, you really feel like you have their support and they take your input."

Attractive approach

Although the nursing shortage is an ever-present problem in health care, PACE programs have a healthy retention record. "A lot of nurses are more interested in community practice these days and a team environment where you've got colleagues you're working with," Hansen said. "You see your patients over several years. There's a real sense of relationship you have with your participant. You really know them as part of a family."

Margaret Gunzelman, RN, worked at a nursing home for 20 years before discovering the Hopkins ElderPlus PACE program in Baltimore two years ago.

"I love it here. I like the team approach. There are so many people to solve a problem," she said. "Instead of just distributing medication, I get to use my expertise. I get to be more creative than I would be in an institutional setting."

The staff at Hopkins ElderPlus receive continuous kudos from family caregivers of the program's 130 participants, Gunzelman said.

"A lot of families have said they wouldn't know what to do without us. We pay for medication, as well as supplies, which can be so expensive. We've even gone out and put ramps in, microwaves, air conditioners … Whatever it takes to keep them at home," she said. "It's cheaper to pay $150 for an air conditioner than have someone with congestive heart failure in the hospital because it's hot and humid outside."

As Gunzelman points out, in addition to health and career benefits, PACE saves money.

The On Lok program, for example, saves Medicare about 5 percent and Medicaid about 10 percent by having seniors in PACE rather than a nursing facility. Nationally, PACE keeps hospitalization costs down for its seniors.

According to a study cited by the Center for Medicare Education, when PACE participants are admitted to the hospital, they stay an average of 4.6 days, compared with 6.4 days for the Medicare population as a whole.

"Missouri loves us because it is cheaper to keep an individual out of a nursing home and have a PACE program attend to her," said Deborah Bland, MHA, RN, site director for Alexian Brothers Community Services PACE center in St. Louis.

Bland describes her 180 participants as the "frailest of the frail. They are sicker than the average nursing home patient," she said.

"There isn't a day you will come into this program that someone doesn't say, 'These people should be in a nursing home-these people are really sick!' But there's not much we can't handle. We do EKG, pulse oximetry, X-ray, lab services, oxygen therapy. It becomes a day hospital for many people."

PACE is a model that "for many people, really works," said Gretchen Brickson, MBA-MPH. Brickson has worked in various capacities in the field of senior care for years, and now is wading through the state and federal application process to start a PACE center at Downey Regional Medical Center in Southern California.

"You see people's quality of life improve, some of their really serious conditions stabilize, and it helps people live more independently," Brickson said. "The team approach is effective. When you give that much attention, it really makes a difference in people's lives."

Contact Janet Wells at janetawells@hotmail.com