The Program of All-Inclusive Care for the Elderly (PACE): an innovative long-term care model in the United States

This article examines the long-term care service system in the United States, its problems, and an improved long-term care model. Problematic quality of care in institutional settings and fragmentation of service coordination in community-based settings are two major issues in the traditional long-term care system. The Program of All-Inclusive Care for the Elderly (PACE) has been emerging since the 1970s to address these issues, particularly because most frail elders prefer community-based to institutional care. The Balanced Budget Act of 1997 made PACE a permanent provider type under Medicare and granted states the option of paying a capitation rate for PACE services under Medicaid. The PACE model is a managed long-term care system that provides frail elders alternatives to nursing home life. The PACE program's primary goals are to maximize each frail elderly participant's autonomy and continued community residence, and to provide quality care at a lower cost than Medicare, Medicaid, and private-pay participants, who pay in the traditional fee-for-service system. In exchange for Medicare and Medicaid fixed monthly payments for each participating frail elder, PACE service systems provide a continuum of long-term care services, including hospital and nursing home care, and bear full financial risk. Integration of acute and long-term care services in the PACE model allows care of frail elders with multiple problems by a single service organization that can provide a full range of services. PACE's range of services and organizational features are discussed.     

Medicaid Managed Care Programs for High-Risk Older People in Massachusetts

The Commonwealth of Massachusetts has undertaken a major initiative in the development of comprehensive managed health care programs for two sets of high-risk older people: those who are frail and homebound and those who reside in nursing homes. This effort has been coordinated by the state's Department of Public Welfare (DPW; Medical Assistance [Medicaid] Program) and Executive Office of Elder Affairs, and expedited ba a set of Health Care Financy Administration (HCFA) waivers and by the state's revised Nurse Practice Act (MGS Chapter 56). Than act allows nurse-practioners and physician assistants expanded roles as primary providers in home care and nursing home settings. The managed care initiatives have supplemented other efforts (1) to coordinate health and social services for older people, (2) to provide as broad a range as possible of community-based services for older people, and (3) to enroll as many older adults as possible in Health Maintenance Organization (HMO) "Senior Plans" and other similar "Competive Medical Plans."

Though there is still no evidence of the managed care programs' effects, this article summarizes some of the possible risks and benefits of managed care programs for those kinds of populations and presents an agenda of questions that evaluations of managed care programs must address.     

Medicaid Beneficiaries' Access to Residential Care Settings

Residential care settings (RCSs) are community-based housing and supportive services providers. Medicaid beneficiaries' access to RCSs is of concern to policymakers and other stakeholders because most people prefer community-based to institutional services and RCSs are generally less expensive than nursing homes. To better understand Medicaid beneficiaries' access to state-licensed RCSs, we examined Medicaid policies in 50 states and the District of Columbia, interviewed seven subject-matter experts, and conducted four state case studies informed by reviews of state policies and interviews with 27 stakeholders. Factors identified as influencing Medicaid beneficiaries' access to RCSs include Medicaid reimbursement rates for RCS services, the supply of Medicaid-certified RCSs and RCS beds, and policies that affect RCS room and board costs for Medicaid beneficiaries. Shifting Medicaid spending toward community-based instead of institutional care may require attention to these interrelated issues of RCS payment, supply, and room and board costs.     

Resource Effects on Access to Long-Term Care for Frail Older People

Abstract

Access to long-term care depends primarily on personal resources, including family members and income, and on external resources, including Medicaid and Medicare. This study investigates how resources affect frail older individuals' access to long-term care, with a focus on Black and White widows. Data from the 1989 National Long-Term Care Survey is used, in conjunction with state-level Medicaid and Medicare reimbursement rates for nursing home and home health care, to estimate the likelihood of five types of care arrangements. Results show that children are a primary resource for unmarried individuals in maintaining access to informal care. Income effects are nonlinear in relation to nursing home care: increasing incomes below the mean income are associated with decreasing probabilities of nursing home care, while increasing incomes above the mean are associated with increasing probabilities of nursing home care. Income and Medicaid effects are interrelated, with nonlinearities associated with income having the potential to adversely affect some older persons' ability to access nursing home care.     

Transition from Home Care to Nursing Home: Unmet Needs in a Home- and Community-Based Program for Older Adults

A major effort is under way nationally to shift long-term care services from institutional to home- and community-based settings. This article employs quantitative and qualitative methods to identify unmet needs of consumers who transition from a statewide home- and community-based service program for older adults to long-term nursing home residence. Administrative data, care manager notes, and focus group discussions identified program service gaps that inadequately accommodated acute health problems, mental health issues, and stressed family caregivers; additional unmet needs highlighted an inadequate workforce, transportation barriers, and limited supportive housing options. National and state-level policy implications are considered.     

Comparing States' Medicaid Nursing Facilities and Home and Community-Based Services Long-Term Care Programs: Quality and Fit with Inclination,Capacity, and Need

States employ home and community-based services (HCBS) increasingly in Medicaid support of long-term care and rely less on nursing facilities. We examine how states' nursing facilities and HCBS programs compare and whether states' long-term care responses match their ideological inclination toward, material capacity for supporting, and their citizens' need for these public social programs. We use cross-sectional panel data on structural, process, and outcome quality for nursing facilities and HCBS congregate residential programs. We rank states, correlate these measures, and use regression to link inclination, capacity, and need to quality. We find that states' nursing facility and HCBS program quality are not closely related and that state HCBS congregate residential program quality is independent of inclination, capacity, and need. This latter result underscores a need for uniform HCBS standards and better data on quality.     

Strengthening home and community-based care through Medicaid waivers

States are increasingly using the Medicaid 1915c waiver program to provide community-based long-term care (LTC). We examined state predictors of waiver utilization and expenditures for waivers serving both older and working-age individuals. State level data for the period 1992 to 2001 were used to estimate random effects panel models. States with increased community-based care (e.g., home health agencies) and decreased nursing home bed capacity were positively associated with state per capita rates of use, expenditures, and the share of Medicaid LTC dollars supporting 1915c waivers. States appeared to substitute Medicare for Medicaid services for individuals eligible for both. State per capita income was positively related to each measure. State policies that facilitate decreased institutional and increased community- based capacity appear essential to state efforts to expand access to community-based services. Federal policies that address state resource issues may also spur growth in community-based LTC, which, in most states, continues to be limited.     

Workforce Issues in Residential Care Facilities in Rural China

This study examined contemporary frontline workforce issues related to residential care for elders in rural China. Residential facilities in rural China are in transition from exclusively providing shelter to childless elders to providing long-term care for frail elders. These facilities are also under pressure to improve the quality of services that they provide. The study is based on in-depth interviews with administrators and field observations of facilities. The study focused on the following issues related to the workforce: recruitment and retention, training, work environment, workforce organization, regulations, compensation, and career ladders. The implications of resident characteristics for demands on the work force were examined. The study found that lack of skilled personnel is one of the major reasons that the overwhelming majority of facilities deny admission to frail and demented elders. Improving workers’ skill is critical if these facilities are to meet the increasing demand for institutional long-term care needs.     

Adding Long-Term Care to Medicare

The rancor accompanying the repeal of most of the 1988 Medicare Catastrophic Act reflects both the national need to improve health and long-term care benefits for the elderly and the political obstacles to finding new sources of financing for such benefits. Neither the need nor the obstacles will go away, but policymakers are now likely to look for lower-cost, efficient, and privately funded alternatives. The authors have developed and tested one such approach: the Social Health Maintenance organization (SHMO). Operating since 1985. the SHMO model integrates community-based, long-term care services into the managed,prepaid HMO design. The four test sites are adding long-term care to Medicare at no extra cost to the government and only modest premiums for the 17,000 current members. Although the benefits offer limited protection for long-term nursing home care, they do cover long-term care in community settings, where people tend to prefer to stay. Also, integration of the acute and long-term care s stems improves the ability to respond to the medical needs of frail members, who also have high acute-care use. The SHMO's model of front-end, community-oriented, long-term care benefits integrated with Medicare appears to be a practical, affordable, and clinically appropriate way to address the rising concern with the lack of coverage and services for long-term care.     

Does Home- and Community-Based Care Affect Nursing Home Use?

A study was conducted to assess change in numbers, expenditures, and case mix of nursing home residents as Medicaid investment in home- and community-based services (HCBS) 1915(c) waivers increased in seven states. The seven states provided Medicaid expenditure and utilization data from 2001 to 2005, including waiver and state plan utilization. The Minimum Data Set was used for nursing home residents. For three states, community assessment data were also used. In six states, the number of nursing home clients decreased as the numbers of HCBS clients grew. However, in most states, the number of additional waiver clients often greatly exceeded reductions in nursing home residents. Nursing home payments decreased moderately, but this decrease was offset by increases in HCBS waiver and state plan expenditures, leading to a net increase in long-term support services (LTSS) expenditures from 2001 to 2005. Increases in waiver expenditures outpaced increases in waiver clients, indicating expansion of services on top of expansion in clients. States that showed substantial increases in HCBS showed only modest increases in nursing home case mix. The case mix for nursing home residents was more acute than that for HCBS users. The expectation that greater HCBS use would siphon off less severe LTSS users and hence lead to a higher case mix in nursing homes was partially met. The more acute case mix in nursing homes suggests that HCBS serves some individuals who were previously cared for in nursing homes but many who were not. Efforts to promote substitution of HCBS for institutional care will require more proactive strategies such as diversion.     

Resource effects on access to long-term care for frail older people

Access to long-term care depends primarily on personal resources, including family members and income, and on external resources, including Medicaid and Medicare. This study investigates how resources affect frail older individuals' access to long-term care, with a focus on Black and White widows. Data from the 1989 National Long-Term Care Survey is used, in conjunction with state-level Medicaid and Medicare reimbursement rates for nursing home and home health care, to estimate the likelihood of five types of care arrangements. Results show that children are a primary resource for unmarried individuals in maintaining access to informal care. Income effects are nonlinear in relation to nursing home care: increasing incomes below the mean income are associated with decreasing probabilities of nursing home care, while increasing incomes above the mean are associated with increasing probabilities of nursing home care. Income and Medicaid effects are interrelated, with nonlinearities associated with income having the potential to adversely affect some older persons' ability to access nursing home care.     

Elders with Serious Mental Illness: Lost Opportunities and New Policy Options

This article reviews key federal Medicaid policies affecting older adults with serious, long-term mental illness: (a) the Medicaid exclusion of coverage for Institutions for Mental Diseases, (b) the Preadmission Screening and Resident Review Process, and (c) the Medicaid Home and Community Based Services waiver policy. Documenting the incentives and restrictions in these policies provides an historical context for understanding the current gaps in treatment for elders with mental illness. New federal options under the Deficit Reduction Act may provide opportunities for reducing the institutional bias for older adults with mental illness and for improving mental health services for elders under Medicaid.     

State commitment to home and community-based services: effects on independent living for older unmarried women

This study examines the impact of state variation in commitment to the provision of home and community-based services on the living arrangement outcomes of older unmarried females with functionallimitations. We combine data from the 1990 U.S. Census of Population (PUMS) with state-level information on long-term care home and community- based service expenditures, nursing home bed availability, and Medicaid nursing home costs from a special report that compares state variation in long-term care systems. Using multilevel logistic regression modeling techniques, we find that the risk of institutionalization compared to community living arrangements is reduced as spending for home and community-based services at the state level increases. We discuss these findings in light of policy changes during the 1990s.     

Transition from home care to nursing home: unmet needs in a home- and community-based program for older adults

A major effort is under way nationally to shift long-term care services from institutional to home- and community-based settings. This article employs quantitative and qualitative methods to identify unmet needs of consumers who transition from a statewide home- and community-based service program for older adults to long-term nursing home residence. Administrative data, care manager notes, and focus group discussions identified program service gaps that inadequately accommodated acute health problems, mental health issues, and stressed family caregivers; additional unmet needs highlighted an inadequate workforce, transportation barriers, and limited supportive housing options. National and state-level policy implications are considered.     

Inclusion of Caregiver Supports and Services in Home- and Community-Based Service Programs: Recent Reports from State Units on Aging

Caregivers have an important role in assisting frail and/or disabled individuals to maintain their independence in the community. Support to assist caregivers in this often stressful and demanding role is critical to sustaining the caregivers' health and ability to provide care. This paper reviews federal policy changes since 2000 that have expanded and enhanced services for informal caregivers. Next, data collected from State Units on Aging and other state agencies are presented to describe the extent to which caregiver services are included in home- and community-based programs under three funding streams (Medicaid waivers, Centers for Medicare and Medicaid Services–funded programs, and state-funded programs). Program characteristics, such as eligibility and consumer-directed options, are included. Finally, the accomplishments and initiatives reported by state respondents related to supporting informal caregivers are also explained. Results indicate that services for informal caregivers are receiving greater attention and are frequently offered under home- and community-based service programs by the states that participated in this study.     

A Focus on the Program of All-Inclusive Care for the Elderly (PACE)

For over four decades, the Program of All-Inclusive Care for the Elderly (PACE) has been operated by nonprofit organizations. Research has demonstrated that nonprofit PACE provides quality, cost-effective community-based care to older adults who would otherwise require a nursing home level of care. Recently, the U.S. Secretary of the Department of Health and Human Services has authorized for-profit entities to operate PACE, contingent on their ability to demonstrate that they can provide care that is similar to nonprofit PACE with regard to access to care, quality of care, and cost-effectiveness. In 2013, a study was conducted to evaluate how PACE operates under for-profit versus nonprofit status. The results were presented to Congress which, in turn, authorized for-profit PACE providers. This article critiques the 2013 study, offers a comparison to for-profit hospice, and argues that at best there is not enough evidence to conclude that for-profit PACE provides the same quality of care as existing nonprofit operators.     

Adding long-term care to Medicare: The Social HMO Experience

The rancor accompanying the repeal of most of the 1988 Medicare Catastrophic Act reflects both the national need to improve health and long-term care benefits for the elderly and the political obstacles to finding new sources of financing for such benefits. Neither the need nor the obstacles will go away, but policymakers are now likely to look for lower-cost, efficient, and privately funded alternatives. The authors have developed and tested one such approach: the Social Health Maintenance Organization (SHMO). Operating since 1985, the SHMO model integrates community-based, long-term care services into the managed, prepaid HMO design. The four test sites are adding long-term care to Medicare at no extra cost to the government and only modest premiums for the 17,000 current members. Although the benefits offer limited protection for long-term nursing home care, they do cover long-term care in community settings, where people tend to prefer to stay. Also, integration of the acute and long-term care systems improves the ability to respond to the medical needs of frail members, who also have high acute-care use. The SHMO's model of front-end, community-oriented, long-term care benefits integrated with Medicare appears to be a practical, affordable, and clinically appropriate way to address the rising concern with the lack of coverage and services for long-term care.     

Emerging Services for Community-Based Long-Term Care in Urban China

Abstract

China's rapid economic reforms, coupled with the changes in age composition of the demographic structure, have greatly affected the traditional family support system. In response to these changes, efforts to develop new models of community-based long-term care (CBLTC) for elders in China have received growing attention. This paper provides a systematic analysis of the current status of emerging CBLTC systems in Shanghai, China. It covers several domains of the system: service delivery, workforce, financing, and quality of care management. Several main issues involved in the development of the emerging system are addressed, and relevant policy implications are presented in the paper.     

Distribution and Utilization of Home- and Community-Based Long-Term Care Services for the Elderly in North Carolina

ABSTRACT

Provision of home- and community-based long-term care is a growing concern at the national, state, and local levels. As more persons grow old, the need for these services is expected to rise. This analysis examines the distribution and utilization of three home- and community-based long-term care programs in North Carolina for each of the state's 100 counties. Maps were generated to examine how counties differed in respect to service utilization among the elderly. Great variability was found in number of elderly utilizing the services across the state as well as the percent of Medicaid- and/or age-eligible persons who utilized the programs. Multivariate modeling for associations to service utilization was only possible for one of the long-term care programs. Results indicated that living alone, being non-white, and having a mobility and self-care limitation were all positively related to utilization. Percent of persons 85 years or older and the ratio of institutionalized long-term care beds were negatively associated with utilization. It was concluded that states must engage in concerted efforts to ensure equity in access to home- and community-based long-term care.