Sick To Death > Chapter 3 > PACE: All-Inclusive Care
The Program of All-Inclusive Care of the Elderly extends its comprehensive housing, personal, and health-care services to persons eligible for nursing- home care, mostly under a dual capitation from Medicare and Medicaid (capitation involves a uniform per capita payment, regardless of treatment individual patients require; a few patients pay Medicaid's part on their own). Because they must be disabled and nursing-home eligible, PACE patients are almost always living with an eventually fatal chronic condition. PACE is not seen as an end-of-life service, and there are no prognostic requirements for enrollment. But PACE programs cannot discharge enrollees except for a few unusual reasons, so most patients die while in the program and are substantially disabled throughout. PACE is small but illuminating as a program targeted at the last years of life, mostly to people in a frailty trajectory.
PACE programs provide the following services (National PACE Association 2003):
Using interdisciplinary teams, the PACE program is responsible for all services that Medicare or Medicaid would have provided. PACE programs pool all payments from Medicare, Medicaid, and private sources to create a single fund to pay for all covered and supplementary services, giving programs substantial flexibility in services provided. PACE programs can use their funds to support day care, housing adaptations, disposable supplies, and other elements that are not part of the standard "package" of covered services.
In 2002, twenty-eight PACE sites and ten pre-PACE (in development) sites served more than ten thousand patients around the country (National PACE Association 2002). The majority of these patients are quite old and very frail. The profile of a typical PACE participant is like that of the average nursing-home resident: she is eighty years old, has about eight chronic medical conditions, and needs help with three activities of daily living (such as mobility, dressing, and toileting). Among PACE participants, 49 percent have been diagnosed with dementia (National PACE Association 2000). In 2001, PACE received $1.3 million in federal funding for expansion efforts.
Formal evaluation of PACE is under way, and initial reports show good rates of satisfaction with the services and uncertain effects upon costs of care (White, Abel, and Kidder 2000). A 1997 study of Medicare's expenditures for a comparably elderly and frail population found that PACE yields Medicare a 12 percent savings (Gruenberg and Kaganova 1997). In 1998, the median Medicare capitation rate for PACE was $1,226 per enrollee per month, with a range of $877 to $1,775, depending on locale (Catholic Health Association 2003). The Medicaid contribution varies much more, being set by each state. The PACE sites are quite varied in their services, patients enrolled, and setting (Temkin- Greener and Mukamel 2002).
PACE programs emphasize socialization, recreation, rehabilitation to maintain function, and secondary prevention. The success of PACE programs in meeting the needs of frail elders offers lessons in how to care for people facing death as a result of dementia or frailty. The PACE program has demonstrated the effectiveness of creating a flexible program that is tailored to the needs of individual patients and families.
While other programs struggle to provide continuity and comprehensive care, PACE has learned to rely on all of its staff members to monitor participants' health and to watch for signs that a person may be failing. For instance, drivers who pick up patients to attend PACE centers watch for changes in patients' mobility and report these to health-care staff.
PACE has been slow to grow to serve more people, despite substantial support from philanthropies and the federal government. Patients sometimes resist referral, often fearing loss of their usual doctor and sometimes resisting use of the adult day-care center. States have been slow to set Medicaid rates, in part because PACE's focus on out-of-hospital care can effectively shift costs from Medicare-covered hospitalization to Medicaid-covered supportive care. Mostly, though, slow growth probably reflects resistance to change, even with evidence of improved care. Early evaluations of the model have shown that it reduces the use of hospitals and nursing homes. Yet PACE has proven difficult to implement, recruitment has been slow, and its net effects on total health- care costs and on patients' functional ability and health status are not yet clear (Boult et al. 2000).
Other interventions aiming to provide more comprehensive management of chronic illness patients have included interdisciplinary home care, disease management, ACE units (hospital-based acute care for elders), geriatric evaluation and management, and case management.