Silver Linings: Program shows promise by keeping frail elders independent
Faith Horan has seven cardiac stents, a pacemaker, macular degeneration and diabetes, and she's about to start dialysis - and that's where her diagnoses begin.
"It's a shorter list of what I don't have," joked the 68-year-old from Lowell, Mass. "I am a teenager in altered packaging."
Horan and her husband, Michael, have chronic conditions that qualify them for nursing home care, which in Massachusetts averages about $128,000 a year for a shared room. In her case, that would be paid for with taxpayer dollars.
But the Horans are living well at home, enrolled in a frail elder health-care program called the Programs of All-Inclusive Care for the Elderly (PACE). The goal is to keep patients out of expensive nursing homes by giving them rides to a community center where they receive medical care, physical or occupational therapy, dental work, or just a lunch and a game of bingo.
Enrollees can go any weekday they want and as often as they want. They pay nothing out of pocket, whether it's for prescriptions, X-rays, a cooking class, acupuncture or a turkey sandwich. A salon will soon open at the PACE facility Horan attends.
"They aren't just treating your body," Horan said. "They are treating your soul."
It seems to be working. Robert Greenwood of the National PACE Association said 95 percent of all enrollees nationwide are living at home. All 31 states with PACE programs have reported happier, healthier patients. A study of Massachusetts PACE programs found an 18 percent reduction in the risk of death for patients in their first year.
Many states report a cost savings in Medicaid spending, the government insurance program managed by states that pays for the bulk of nursing care in the United States. Texas reported a 17 percent savings and Tennessee reported a 14 percent savings, with PACE patients spending less time in hospitals. Massachusetts reported a 14 percent drop in nursing home residency, with a 20 percent shorter stay for PACE patients.
The savings comes through a bundled payment program, with Medicare and Medicaid paying a monthly, per-patient fee. If a patient remains healthy, PACE makes money. If a patient gets sicker or needs nursing home care, PACE is on the hook no matter what the cost, Greenwood explained.
It's a program promoted by the federal Center for Medicare & Medicaid Innovation. New Hampshire, the state with the second oldest population in the country, has no PACE programs.
Kenneth Comeiro is a nurse practitioner at Element Care in Lowell, the PACE program that Horan attends. He said PACE-like programs must be the future of elder health care.
"If we don't do something like we do at PACE, there's going to be problems," Comeiro said. "We're going to see more and more older adults, and it's going to cost more and it will affect quality of life."
To qualify for PACE, a patient must be certified by Medicare as nursing-home eligible. Most states, like Massachusetts, require a patient be lower income and eligible to receive Medicaid. Greenwood said some programs have dropped the Medicaid requirement, allowing those who receive only Medicare, or are private payers, to join the program. The patient must also be considered frail with more than one chronic condition.
Dr. Jenny Chiang at Element said it's difficult to say how many conditions her patients have because health care has switched to codes to classify diagnoses. For example, a person with a bad knee may have several codes to explain their one condition. These codes don't reflect the severity of the need of her PACE patients, she said.
"It's not unusual for me to see patients with 20 or 30 diagnosis codes, some with 70 or over 100," she said. "It doesn't really capture the level of sickness."
The National PACE Association reports the average age of enrollees is 77; 70 percent are women. Most are dealing with several health issues, mostly vascular diseases, diabetes, congestive heart failure, depression, and chronic obstructive pulmonary disease. About 47 percent have some sort of dementia.
Element opened a little over a year ago, has 73 patients, and a capacity for 500. Comeiro said he's noticed a trend in the new enrollees.
"The new people we enroll are sicker," he said.
Walking into Element in Lowell is like entering an inviting hotel lobby. Circular booths line large picture windows in a downtown building that once served as a bank. Seniors gather around big round tables and sit in loungers while a nurse practitioner keeps watch.
Horan sits at one of the booths with Comeiro. He makes a joke about her husband and then asks about her foot. He examines her foot and offers advice and that's considered her medical appointment for the day.
Comeiro and Chiang are just two pieces of the interdisciplinary team at Element, which includes social workers, mental and behavioral counselors, nutritionists, physical therapists, a dentist, personal care attendants, and the person who drives the bus. Each is responsible for a piece of the patient's care.
"I tell them this is going to be their second family," said Chiang. "It's like going to Thanksgiving dinner. You might get frustrated with us because we're telling you what to do, but it's because we all care for you."
Chiang is a geriatrician who previously worked at a health clinic. She said her heavy load of patients was squeezed into a schedule that often only allowed for 15-minute appointments. At Element, there are no time constraints on a patient. She will see them in the center, at their home, or if need be, in the hospital.
"Sometimes I will spend an hour with a patient, and sometimes I'll spend two hours. Other times, it's 10 minutes," she said.
The goal is the same for every patient - to live happy and healthy at home, Chiang said.
"Losing your independence is like losing your life," she said.
A growing trend
Medicaid is the primary payer of nursing home stays in the United States, and about 90 percent of PACE patients receive it, according to the National PACE Association.
In Fiscal Year 2015, 51 percent of all Medicaid dollars in New Hampshire went to nursing homes, according to the Kaiser Family Foundation. In 2015, the median cost of a year in a New Hampshire nursing home was $80,300, according to Genworth Research.
Massachusetts, with 23 PACE centers, spends 30 percent of Medicaid money on nursing home care.
Many studies show little to no difference in the cost between a frail elder in PACE and one that is not. The savings result when a non-PACE patient goes into a nursing home. Results vary from state to state, but a 2013 state-sponsored study in Kansas showed a savings of $1,136 per month between a PACE enrollee and a traditional nursing home patient.
Chiang said she sees the PACE program as part of a trend in paying for health care. Using bundled payment systems instead of fee-for-every-service provided systems will not only lead to cost savings but better care, she said.
"I think we are recognizing that health care is more than just about the disease and the cure," Chiang said. "It's about the care."
Horan has a sister who is an amputee living in Nashua who wants PACE care and will likely be moving to the Lowell area to receive it.
"People don't do enough or say enough about the elderly," Horan said. "They are going to be biggest population, and it's coming soon."