Can hospices keep PACE with end-of-life care?
Some experts say the two approaches can coexist
If you haven’t heard about PACE yet, you will soon. The Program of All-inclusive Care for the Elderly (PACE) is a health care delivery model that is growing rapidly, thanks to a provision in the Balanced Budget Act of 1997 giving it permanent provider status. Increasing numbers of hospices will find themselves working with PACE programs, or in some cases, part of a PACE program.
"PACE’s philosophy is very much in line with what we believe in terms of being able to work with individuals in their homes and helping them to remain independent with dignity as long as possible," says Terrye Bradley, MSW, director of community programs for The Hospice of the Florida Suncoast in Largo, FL.
Bradley recently contacted the National PACE Association in San Francisco to obtain more information about the model. The hospice is looking for the best method to serve its population, which could mean collaborating with a PACE program if one were started in the Tampa-St. Petersburg area, Bradley says.
PACE is an alternative medical model that provides frail elderly people with an array of health services, all under one umbrella. Medicare and Medicaid pay many PACE programs on a capitated basis, meaning the programs receive a set amount of money per month per enrollee in exchange for providing all of the necessary hospitalization, medical- surgical, long-term, hospice, home health, rehabilitation, and day care services. (See story on how PACE was started, p. 30.)
"PACE is essentially a hybrid between an insurer and provider," says Judy Baskins, RN, vice president of geriatric services at Columbia, S C-based Palmetto Richland Memorial Hospital, which has a PACE program called Palmetto SeniorCare. Baskins also is the president of the National PACE Association.
The PACE delivery system is built around the concept of a day center, but it’s more extensive, with its own community of providers. "It’s a nursing home without walls," Baskins explains.
"You bring the individual into a day center during the day, and they receive physician services, occupational therapy, physical therapy, skilled nursing care, and social activities," she says. "It provides respite for families and meets a whole variety of medical, health, and social needs."
PACE targets chronically ill
When the patient’s care becomes more medically complex, the PACE team may include more of a home care component. Since PACE programs work with people who are typically 80 years or older and frail, these programs make end-of-life care a priority.
"PACE truly embraces the concepts of hospice better than any other aspects of the health care system," Baskins says. "However, our focus is not just on the immediate end of life, but on the several years prior to the end of life."
PACE works with chronic, long-term disease processes. PACE patients may include those with Alzheimer’s, hypertension, cardiovascular disease, diabetes, and end-stage renal disease. They are not the typical cancer patients, as is often the case in hospice care, Baskins says.
"The target markets are patients who would receive long-term institutionalized care," she explains. "A subset of the population does have cancer, but it’s not the top disease that we provide care for."
About 11% of PACE patients die each year, says Ellen Tishman, RN, MPH, executive director of the National PACE Association. "We’re not a substitute for hospice in any way, but a number of the folks we work with are at the very end stages of their lives."
When patients reach the last weeks of their lives, PACE may contract with hospices to provide skilled nursing visits, but the PACE providers continue to manage the patient’s care, Baskins says.
"PACE does provide hospice care, and we found it unfair to take away all of the other PACE care just because patients become predictably terminal," she adds.
For example, PACE typically provides a dying patient with homemaker services, and physician and nurse practitioner home visits. PACE pro-viders also tend to dying patients’ emotional care. Social workers are intimately involved and provide follow-up care for caregivers and family members after the patient’s death. PACE also provides support groups for caregivers and families.
The PACE model’s fairly recent move into mainstream provider status echoes what happened with the hospice concept within the past 20 years, experts note.
"The closest parallel is when hospice moved out of home health and became a separate provider," Baskins says.
Hospices and PACE programs could form partnerships in a couple of different ways, Tishman suggests. Those include:
• A PACE program could contract with a hospice provider for hospice care, and PACE would pay for the patient’s care rather than have the hospice bill Medicare on a fee-for-service basis.
• Hospices and PACE programs could have an informal sharing of intellectual property around end-of-life issues, referral, and training.
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