Community-based integrated care (CBIC) is designed to keep older adults where they want to be – at home and out of hospitals and nursing homes. The Program of All-Inclusive Care for the Elderly (PACE) is an example of successful CBIC, established in 1985 as an innovative solution to pervasive issue: how to provide integrated care to a high-risk population of older adults that promotes community living (not a nursing home) in a cost-effective manner.
This unique guide provides readers with a concise yet informative base of understanding of PACE as well as a “deep dive” into the components and job roles that will serve as a reference for existing PACE providers and will inform those who are considering the possibility of developing a new PACE program. Chapters are organized into five thematic sections. Part one presents both domestic and international perspectives on CBIC, with part two delving deeper into the US PACE model, including its history, policy evolution and effectiveness. Specifics regarding the organization and management of PACE and the essential roles and positions comprise parts three and four, respectively, from leadership and the involvement of the state to the roles of the social worker, nurse, nutritionist, rehabilitation specialist, and more. Care planning, coordination and end of life care round out part five.
In addition to geriatricians and other clinical practitioners involved with the care of older patients, Community-Based Integrated Care for Older Adults is also a resource for scholars, policy makers and the general public who are interested in innovations in long-term care that provide older adults with alternatives to nursing homes.
Author(s): Matthew K. McNabney
Publisher: Springer
Year: 2022
Language: English
Pages: 261
City: Cham
Preface
Contents
Contributors
Part I: Community-Based Integrated Care
Chapter 1: The International Perspective on Community-Based Integrated Care
Introduction
Canada
Germany
Germany’s Older Population
The Seventh Government Report on the Situation of Older People: Care and Shared Responsibility in the Municipal Community
Health Promotion and Provision and Care for Older People in the Context of Community-Based Integrated Care
Prospects for Building Community-Based Integrated Care for Older People
Japan
South Korea
Summary
References
Chapter 2: The United States Perspective on Community-Based Integrated Care
What Is “Integrated, Community-Based Care?”
What Makes Integrated Community-Based Care Teams Unique?
What Makes Community-Based Integrated Care Successful?
Who Pays for the Services?
What Does the Future Hold?
Future Policy Direction
References
Part II: The U.S. Prototype: Program of All-Inclusive Care for the Elderly (PACE)
Chapter 3: History and Policy Evolution of the PACE Model of Care
The PACE Model of Care
History of On Lok and PACE
PACE Federal Policy Milestones
Permanent Provider Status
Benefit Improvement and Protection Act of 2000 PACE Waivers
Medicare Part D Prescription Drug Benefit
Rural PACE Pilot Act
Strategic Efforts to Support the Expansion of PACE
PACE Expansion Initiative (PEI)
Expanding Provider Capacity
Development and Dissemination of Written Products
Development and Implementation of Training Sessions and Accompanying Materials
Specialized Technical Assistance
State Policy Activities
Expanding Awareness of PACE Among Consumers, Providers, and Policy Makers
Accelerating Access to PACE (ASAP)
Rural PACE: Meeting the Challenge
PACE 2.0: Adapting and Disseminating PACE to Serve High-Need, High-Cost Populations
COVID-19 Pandemic Impact on PACE
Summary
Suggested Reading
Chapter 4: Evaluating the Effectiveness of PACE
Introduction
Research Designs and Comparator Groups for Evaluating the Effectiveness of PACE
Evaluation of the Effectiveness of PACE
Effectiveness in Reducing Mortality
Effectiveness in Reducing Hospitalization
Effectiveness in Reducing Nursing Facility Admission/Utilization
Effect on Medicaid and Medicare Spending
Effectiveness in Improving Potential Metrics of Quality of Care
Effectiveness as Measured by Satisfaction with Care and Quality of Life
Summary
References
Part III: The Organization and Management of PACE
Chapter 5: Leadership in PACE
The Call to Serve—Creating a Sense of Mission
Begin with a Leadership Team
A Vision for Growth
Promoting “Value Based Care” as a PACE Leader
The Devil Is in the Details
Integration of Palliative Care
Garnering Resources
Summary
References
Chapter 6: Starting and Growing a PACE Program
Starting and Growing a PACE Program
Opening a Pace Program
Mission, Vision, and Values
Owner/Operator Scenarios
Scenario 1: Stand-Alone PACE Program
Scenario 2: PACE Program Owned by a Larger System
Scenario 3: For-Profit PACE Program
Regulatory Steps
State Approval and Partnership
PACE Application
Financing
Initial Investment
Business Plan
Market Analysis
Market Size
Availability of Service Alternatives
Gap Analysis
Risk Management
Growing a Pace Program
The PACE Message and Explaining to the Public
Marketing
Staffing
Marketing Assessment
Marketing Strategies
Referral Sources
Competitors Serving Similar Populations
Enrollment and Growth
Enrollment: The Intake Process
Onboarding Participants
Physical Space
Day Center
Transportation
Health Center (Medical Clinic)
Regulatory Awareness and Compliance
Key Processes and Methods
Summary
References
Chapter 7: The State’s Role in the Implementation of PACE
Introduction
Medicaid and Prospective Providers: Building Support
Why PACE?
State Policy Decisions
State Plan Amendment
Administering Agency
Licensure/Legislation
Service Area
Technical Assistance Center Requirements and Qualifications
Enrollment Limits
Medicaid Rate Setting
State Operational Issues
Procurement Process
State Staffing
Separate Medicaid Agreement
Enrollment Agreement 42 CFR § 460.154 (CFR—Code of Federal Regulations)
Process for Enrollment
Reporting Requirements
Financial
Readiness Reviews
Reporting
Ongoing Monitoring
Complaints and Grievances
Appeals
Disenrollment and Involuntary Disenrollment
Eligibility
Enrollment
Three-Way Program Agreement
Stakeholder Education, Communication, and Buy-in
Internal
Affected Offices
Authority
Legislators
External
Nursing Home Industry
Home Care
Advocacy Organizations
Role of Community/Advisory Committees
Interaction with Medicare + Choice
Things to Consider
Summary
Suggested Reading
Chapter 8: Medication Management and Part D Coverage in PACE
What Is Medicare Part D?
Part D Benefits
Part D Payments
Part D Risk Adjustment
Part D Experience Reporting
Part D Payment Reconciliation
Part D Compliance
Pharmacists in PACE
Regulations and Plan Monitoring
Cost Savings/Cost Avoidance and Therapeutic Interchange
Participant Adherence Assessment
The Evolving Role of the PO Pharmacist
Summary
Chapter 9: Core Components of the Typical PACE Center
The PACE Adult Day Health Center
Overview of Adult Day Care
The PACE Adult Day Program
Summary
The PACE Medical Clinic
Overview on General Medical Practices
The PACE Medical Clinic
Summary
The PACE Rehabilitation Suite
History of Rehabilitative Services
Members of Rehabilitation Team and Their Roles
Rehabilitation Services in a Traditional Non-PACE Model of Care
Rehabilitation Services at the PACE Center
Who Gets Rehab Services in PACE?
Summary
General Summary: The PACE Center
References
Suggested Reading
Part IV: The PACE Team and Essential Roles
Chapter 10: The Interdisciplinary Team and Process in PACE
The IDT in the PACE Model of Care
PACE Interdisciplinary Team
Primary Care Provider
Registered Nurse
Social Worker
Physical Therapist
Occupational Therapist
Center Manager
Dietician
Personal Care Aide
Life Enrichment Coordinator
Driver
Home Care Coordinator
Interdisciplinary Team Meetings
Elements of an Effective IDT
Potential Problems with the IDT Process
Summary
References
Chapter 11: The Role of Social Work in PACE
Social Workers and PACE
Psychosocial Care
Psychosocial Assessment
Psychosocial Intervention
Palliative Care
Behavioral Health
Dementia
Summary
References
Chapter 12: The Role of Recreational Therapy in PACE
Benefits of Recreational Therapy in the PACE Model
Assessment
Care Planning Goals for Recreational Therapy
Participant Goals
Interventions
Putting It All Together
Recreational Therapist Role in the Day Health Center
Recreational Therapy and General Activity Groups
Recreational Therapy and Therapeutic Groups
What RTs Brings to the PACE IDT
Summary
References
Chapter 13: The Role of Transportation in PACE
Transportation for Older Adults in the General Population
Transportation in the Program of All-Inclusive Care for the Elderly (PACE)
Typical Day for PACE Transportation Team
Summary
Suggested Reading
Chapter 14: The Role of Direct Care Providers in PACE
Introduction
Direct Patient Care Providers: What’s in a Name?
Geriatric Nursing Assistant (GNA) and Certified Nursing Assistant (CNA)
CNA Duties and Responsibilities
Medication Technician
Medication Technician Duties and Responsibilities
Administer Patient Medication
Perform Medical Check-Ups
Update Patient Records
Report Patient Complaints to Senior Nurses
General Considerations for Direct Patient Care Providers
Summary
Suggested Reading
Chapter 15: The Role of Nursing in PACE
Registered Nurse (RN)
Home Care Coordinator
Licensed Practical Nurse (LPN)
Nursing Assistants
PACE Administrative Positions
Summary
Suggested Reading
Chapter 16: The Role of Home Care in PACE
General Overview of Home Care
Home Care and the PACE Model
Specific PACE Home Care Services
Home Care Staff Considerations
PACE Home Care and the Interdisciplinary Team
Differences in PACE and Traditional Home Care
Summary
References
Chapter 17: The Role of Medical Providers in PACE
General Medical Providers (Non-PACE)
General Medical Providers in PACE Model
Types of Providers
Important PACE Roles for Medical Providers
Comprehensive Coordinated Primary Care
Care Coordination
End-of-Life Care
Care Planning
Billing/Coding
Summary
Suggested Reading
Chapter 18: The Role of Medical Director in PACE
Introduction
Overview of PACE Medical Director Role
Organization of the Medical Staff
Oversight of Medical Practice
Clinical Coverage
Medical Records
Quality Improvement Program
Utilization Management
Other Medical Director Functions
Summary
References
Chapter 19: The Role of Rehabilitation in PACE
Introduction
PACE Priorities: Rehabilitation and Aging in Place
Beyond Fee-for-Service: Rehabilitation in PACE
The Role of the Rehabilitation Department in PACE
Role of Rehabilitation in Falls Prevention and Home Safety
Role of Rehabilitation in Pain Management
Occupational Therapy and Dementia/Cognition
Tailored Activity Programs
Summary
References
Chapter 20: The Role of Dietician-Nutritionist in PACE
Introduction
The Role of the Dietitian-Nutritionist in PACE
In-Person Nutrition Assessment
Nutrition Requirements & Interventions for the PACE Population
Creative and Hands-on Approaches to Nutrition Education & Intervention
Summary
Suggested Reading
Part V: Special Aspects of the PACE Model
Chapter 21: Care Planning in PACE
Introduction
Care Plans in the PACE Model
When Is a Care Plan Completed?
How Is a Care Plan Created?
Step One: Identify the Needs/Problems of the Participant
Step Two: Set a Goal Addressing Each Problem
Step Three: Determine How the Goal Will Be Met
Step Four: Determine Who Will Be Responsible to Complete or Monitor Each Task
Step Five: Set a Date by Which the Goal Must Be Met
Step Six: Review the Care Plan with the Participant and/or the Primary Caregiver
Documentation of the Care Plan in the PACE Model
Summary
References
Chapter 22: Care Coordination and Transitions of Care in PACE
Summary
Suggested Reading
Chapter 23: End-of-Life Care in PACE
Summary
Suggested Reading
Index
