PACE programs in long-term care (Program of All-inclusive Care for the Elderly)
The Program of All-inclusive Care for the Elderly, better known as PACE, offers the frail elderly an opportunity to remain in the comfort of their homes, amid the familiarity of their communities, while delaying the move to hospital or nursing home.
PACE offers consultant pharmacists an opportunity to expand their roles and become integral players on the interdisciplinary teams through which the innovative program provides total medical care and social services to this fragile, at-risk population.
Chad Morton, consultant pharmacist at Sutter Senior Care, a PACE site in Sacramento, Calif., said he "jumped at the chance" to work with PACE. That was partly because of the services and continuity of care the program offers the elderly and partly because he has "been given a lot of autonomy."
Comparing his work at a PACE facility with his prior nursing home experience, Morton said it is so much more than the traditional monthly chart reviews. He also sits in on the quarterly patient assessment meetings, does infection control, runs a Coumadin clinic, double-checks polypharmacy, checks drug utilization, monitors lab work, is chairman of the P&T committee, and generally is involved in anything having to do with medication.
"No one has asked me to pull back or said, Youre doing too much, or, We cant finance you, so Im taking the ball and running with it."
PACE is modeled after the system of acute and long-term care services developed by San Francisco Chinatowns On-Lok Senior Health Services (On-Lok means "peaceful, happy" in Cantonese). The goal of PACE is to provide the frail elderly and disabled who need intensive long-term care with a financed health, medical, and social services program and the independence to remain at home. The underlying objectives are to give caregiver relief and prevent premature placement in the nursing home simply because the caretaker can no longer do it all 24 hours a day.
In addition to establishing PACE as a permanent provider, the Balanced Budget Act of 1997 raised the cap on the number of nonprofit PACE programs from 15 to 40 in 1998, with an additional 20 each year thereafter. In addition, the act provided for up to 10 for-profit demonstration sites.
A PACE organization must provide a complete service package to the participant regardless of how often or for how long any medical or social services are needed. Each site is built around an adult day care center linked to clinics, and supplemented by in-home and referral services as needed by the participants. PACE sites are financed by Medicare and Medicaid on a capitated basis and must provide all services and medications for that monthly lump sum per participant.
Participants must be at least 55 years old, must live in the PACE service area, and must be certified by the state as needing a nursing home level of care. Participants must switch all their medical care from current providers to the PACE organization. Enrollment in the PACE program is voluntary and participants can choose to leave the program at any time. Patients ineligible for Medicaid can participate by paying privately.
PACE has been described as a program for those elderly who often "fall through the cracks." They may be able to take care of themselves in all areas except medication compliance, for example. Or they may live with a caregiver who must work several days a week, but they cant be left alone. They may be depressed, even have slight dementia, but with carefully monitored medical attention, possibly physical therapy and social interaction, they can continue to live at home for several more years.
Access has always been one of the major issues in this population. And one of the prime purposes of PACE is to remove any barriers to access to the clinic by having transportation bring patients in, or by having the facility transport them to doctors offices for specialty appointments or whatever other services they may need.
Meena Rupani, director of pharmacy at Alexian Brothers Community Services in St. Louis, feels PACEs increased popularity is due to the growing number of families who feel guilty.
"They dont want to put their parent in a nursing home, but theyre under a great deal of pressure because they have children and jobs to take care of also. And then the parent doesnt get taken care of properly. The stress is phenomenal for these peoplebetween the guilt and not having the time and not wanting to put them in a nursing home. But theres been no other alternative until PACE."
Rupani also emphasizes the importance of PACEs flexibility to help all participants, regardless of level of care needed.
"Many of these people are alone and isolated, and they dont get out. When they get in the program and participate in socialization activities, a lot of their problems disappear."
"Just because Grandmother burned a pot once doesnt mean she needs to be in a nursing home," added Morton. "She simply needs someone to go out there and visit a couple times a week, make sure shes taking a shower and make sure shes not posing any risk to herself. We have social workers check in on them and do mental status exams on them. It really is a wonderful way to help these people stay as independent for as long as they can. I really think it is a neat program."
HCFA requires the primary care team to include about a dozen different disciplines, but consultant pharmacist is not among the required list, and not all sites have one.
Palmetto Senior Care in Columbia, S.C., which has been in existence since the inception of the PACE program, has become a successful model for others to follow and a strong advocate for including pharmacy as an integral part of the team.
Judy Baskins, Palmetto v.p., explained, "When the model first started, pharmacy was more of a contract service that provided drugs. But the Pharm.D. is a player at the table and represents a discipline thats very, very appropriate for a geriatric population."
Among the areas in which pharmacists support their geriatrician staff, Baskins cited the issue of polypharmacy, side effects that come with this age group, and the intricacies with interactions of drugs.
"I think we have a younger group of physicians who are much more open to understanding the role of Pharm.D.s," she said.
Palmettos drug utilization numbers proves out the importance of having clinical pharmacy at the table as part of the interdisciplinary team, she added. Compared with the frail elderly nationally, who are on about 10 medicines per patient per day, Palmettos seniors average fewer than five medications per day, including OTCs.
Heather Ashton, one of three Pharm.D.s at the site, has kept track of those numbers on participants, from prior to enrollment through their time with Palmetto Senior Care. Both the pharmacists role and the PACE concept have been instrumental in reducing those pre-enrollment numbers by 50%.
As Ashton explained, "The biggest problem is noncompliance. We meet with the caregivers prior to enrollment and get a comprehensive assessment of what medications the patients are on at the time." When they do pill counts, she said, the solution becomes obvious. "When theyve not filled a prescription since December and its already May, you know they havent been compliant. So you know its going to be a major issue of education for that caregiver."
Each patient whos enrolled at Palmetto Senior Care receives an evaluation by all disciplines every six months. For her pharmacy evaluations, Ashton looks at what medicines the patients are on, making sure theres an indication, making sure the appropriate lab work was done, and that they are on the right dosage. Then she calls the caregivers to see how its going on their sideAre they giving the medications correctly? Are there any problems with seniors swallowing their pills? Is the patient refusing to take any medicines? and so on.
"If I think theres a real issue about noncompliance, I may make a home visit prior to the meeting." She then presents her information at the meeting, and each member of the team has his or her say in that patients plan of care for the next six months.
Without an all-inclusive team care approach like PACE, Ashton said, such noncompliance is often not caught.
"Many of these patients did not have a family physician prior to PACE; some of them simply used the ER when they had a problem. And even those who did have family physicians, often were seeing three or four physicians and going to three or four pharmacies, so it was hard to keep track of all the medications they were taking." But once they enroll in Palmetto Senior Care, that problem is solved. "We have our own pharmacy, all the medicines are supplied by that one pharmacy, and they see only our physicians. So were really able to control the medicines theyre on," she said.
Listening to what Palmettos pharmacists have done convinced Denvers Total Long Term Care to take on a consulting pharmacist, said David Reyes, M.D., its executive director. The fifth PACE site to open, Total Long Term Care has been in operation since 1991 and has had a consultant pharmacist for two years.
"Mostly, hes an invaluable asset in medication management, medication cost, and as an information source," Reyes said. Part of the reason Total Long Term Cares pharmacy costs are within budget this year has to do with the consultant pharmacists input on therapeutic substitutions, he said. "We carefully monitor these, because we want to make sure they do work. And weve had no trouble with any of them."
But Reyes cautions that the least expensive medication is not always what theyre looking at; its more often the overall cost-effectiveness for the program and whats going to work in making sure people take their medications appropriately.
"For example, we will often use a more expensive, once-a-day medication because we have people who come into the day center every day just so we can make sure they take their medicines. Or, well send a nurse out to their homes to give them their medications."
While the larger sites like Palmetto (400 participants) may have several Pharm.D.s plus dispensing pharmacists, Alexian Brothers in St. Louis has 88 participants, so Rupanis role is "all of the above." She handles the clinical, managerial, and dispensing functions. In addition to giving compliance input at daily team meetings, she chairs the P&T committee, does chart runs with the physician, and performs med pass audits.
Whether the facility is large or small, pharmacists can find an important role to fill in the PACE program if given the opportunity. Morton said, "Each PACE site is a little bit different, and each pharmacist does something completely different as well. At some sites, they do just the minimum requirements, and it makes me sad to see that, because theres a neat opportunity here for a pharmacist to really make a difference."
National PACE Association
801 N. Fairfax Street, Suite 309
Alexandria, VA 22314
Dana Cassell. Keeping PACE in long-term care.