PACE: A Model of Care for Individuals with Multiple Chronic Conditions

Abstract: Individuals with multiple chronic conditions place a formidable burden on the healthcare system because of the multiple hospitalizations they often require, many of which are unnecessary or avoidable. The Program of All-Inclusive Care for the Elderly (PACE) is a model of care that grew out of a public health initiative to promote effective and efficient treatment of patients with multiple chronic conditions outside of the hospital setting. PACE incorporates interdisciplinary team care and an adult daycare to meet the needs of older adults with multiple chronic conditions, helping them remain in the community. This article presents a review of the available literature pertaining to the PACE model of care and its ability to reduce hospitalizations in persons with multiple chronic conditions. Core components of PACE, such the adult daycare center and the interdisciplinary team, are discussed, along with the limitations of the model. Policy and practice recommendations for healthcare professionals are also provided, including those for applying the model outside of the United States and as a viable long-term care solution.

Key words: PACE, long-term care, aging, hospitalizations, managing chronic conditions

Citation: Annals of Long-Term Care: Clinical Care and Aging. 2015;23(7):41-45
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The number of people living with multimorbidities, also referred to as multiple chronic conditions (MCCs), is concerning, as multiple chronic illnesses pose a challenge for clinical management and negatively affect health outcomes.¹ In their research, Machlin and Soni² found that, in 2009, an estimated 25% of Americans aged 18 years or older lived with MCCs. Furthermore, the rate of MCCs among older Americans was even higher: of people aged 65 years or older, 67% were treated for ≥2 chronic conditions and 24.6% for ≥4 conditions. Healthcare expenditures increased substantially with the number of MCCs treated: the average health expenses of people with ≥4 chronic conditions were almost twice those of people with two or three conditions and approximately 7-times greater than those of people with no or only one chronic condition.²

As individuals with MCCs age, they experience greater difficulty performing activities of daily living and are at greater risk for multiple hospitalizations.^3,4 Multiple hospitalizations place a formidable burden on the healthcare system, and current solutions for preventing them are not sufficient. There is a growing need for comprehensive models of care in order to reduce hospitalizations of individuals with MCCs.
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The Program of All-Inclusive Care for the Elderly (PACE)
The Program of All-Inclusive Care for the Elderly (PACE) model of care has emerged as a viable solution for the treatment of MCCs in the community setting. PACE was first developed in the early 1970s in a small community in the Chinatown and North Beach neighborhoods of San Francisco, CA, that was struggling to meet the needs of its aging Chinese, Italian, and Filipino immigrants. A long-term care facility was not culturally appropriate or financially feasible for these older adults or for their caregivers, and so they were in need of long-term care alternatives. Developers of the program, including a social worker and a dentist, conceived a model of care based on an adult day hospital or daycare center, a model that was already popular in the United Kingdom, where older adults could attend a center for a variety of services during the day and continue activities of daily living in the community.⁵ Initially, the adult daycare center was called Chinatown-North Beach Health Care Planning and Development Corporation. The name was later changed to “On Lok,” which is Cantonese for peaceful, happy abode.⁶ Healthcare scholars and policy analysts took notice of On Lok’s success, and, in 1986, On Lok’s model was replicated in other states.

The model grew from this small initiative, and its success turned it into to a best-practice care model of the 21st century, with 104 similar programs in operation today.⁷. Some of the organizations operate under the PACE acronym, and others are known as Living Independently for the Elders (LIFE) programs. Using funding from Medicare and Medicaid, PACE programs offer services through a single point of delivery.⁸ As a capitated program, a PACE organization is fully responsible for meeting the healthcare needs of its enrollees, combining the core practices of interdisciplinary team care and an adult daycare center. Individuals are required to meet four basic requirements for enrollment: (1) be 55 years of age or older; (2) be certified by their state of residence as requiring nursing home level of care; (3) live in a safe home environment; and (4) live in an area that is serviceable by a PACE organization.⁷ Enrollees also need to agree to a plan of care and change their primary care provider to a PACE physician. The model of care has been successful, in part, because of its ability to provide services to older adults with MCCs within the community setting, which benefits not only the enrollees but also caregivers who otherwise might not be able to care for their family members.

PACE and Hospitalizations
We conducted a systematic literature review to evaluate the evidence that the PACE model is associated with reduced hospitalizations among individuals who would typically be considered high-risk, namely those with MCCs. We reviewed the available literature on the PACE model of care from PubMed and the National PACE Association’s bibliography of PACE articles and research, using the keywords “PACE,” “long-term care,” “aging,” “hospitalizations,” and “managing chronic conditions.” Anecdotal findings from relevant organizations (eg, the National PACE Association) were included in the review. The literature regarding PACE is substantial; our search returned several hundred articles. We narrowed these down by year, including only abstracts of articles published on or after 1990, the year PACE received Medicare and Medicaid waivers. Articles not focused directly on PACE were also excluded.

The association between the PACE model and reductions in hospitalizations has been studied several times.^9–13 In all of these studies, comprising more than 20 years of data, hospitalization rates have been significantly lower among PACE enrollees than in comparable populations. Wieland and associates9 researched rates of hospitalization among PACE enrollees and concluded that, even though they varied considerably across PACE sites, hospital use among PACE enrollees was low in contrast to that among other older and disabled populations.

Similary, Segelman and colleagues,¹⁰ who researched rates of potentially avoidable hospitalizations across 61 PACE sites, also found variation in the frequency of hospitalizations among PACE sites but concluded that PACE enrollees overall had lower hospitalization and readmission rates by as much as 60% when compared with dually eligible enrollees in other non-PACE, community-based programs. In this study, chronic obstructive pulmonary disease, asthma, and congestive heart failure were responsible for more than 50% of the pulmonary arterial hypertension conditions among PACE enrollees, and yet all of them ranked lower as potentially avoidable hospitalizations in PACE enrollees than in comparable populations. These results suggest that such chronic conditions can be managed in the community without the need for multiple hospitalizations or inpatient hospital services.

In another study, Kane and associates¹⁴ found that PACE enrollees had fewer hospital admissions, preventable admissions, hospital days, and emergency room visits than enrollees in a comparable community-based program. Overall, PACE enrollees visited the hospital less frequently than individuals in a comparable population, and they also stayed at the hospital for a shorter length of time. The positive outcomes observed in this study may be related to care management initiatives at the PACE sites. These results are in keeping with more recent research,^11,13 in which the PACE model of care was associated with better health management outcomes and less hospital use.

Factors Potentially Related to Reduced Hospitalizations with PACE
The reductions in hospitalizations observed among enrollees of PACE programs may be associated with better health management, which may in turn be due to engagement of the interdisciplinary team and use of the adult daycare center. We have not identified any studies that directly recognize these core practices as factors concomitant with reduced hospitalizations, although these two core components of PACE programs are frequently discussed in the PACE literature.

Interdisciplinary Team Engagement
The PACE model of care involves a team of physicians, nurse practitioners, nurses, social workers, physical and occupational therapists, dietitians, and recreational therapists, among others, who evaluate enrollees and develop an individualized plan of care. This interdisciplinary team, as it is known, is similar to other team-based programs in healthcare. Team-based efforts have long been a topic of interest for managed care researchers and policy makers. There is already a substantial body of literature addressing the effectiveness of team-based performance in healthcare^9,15 and several studies discuss its relationship to patient outcomes. The PACE interdisciplinary team is unique, however, in that it includes both professionals and paraprofessionals who take a comprehensive approach to care management. The interdisciplinary team ensures that services are provided throughout the full continuum of care: preventive, primary, acute, rehabilitative, and long-term.⁸

In our literature review, we identified three studies that examine the role of the interdisciplinary team in PACE programs. Of these, one study addressed team performance and its ability to influence outcomes. Temkin-Greener and associates¹⁶ researched interdisciplinary team performance in 26 PACE programs, examining the link between interdisciplinary team effectiveness and three variables: (1) individual characteristics; (2) team characteristics; and (3) PACE characteristics. The latter two were found to influence the perception of interdisciplinary team effectiveness, whereas individual team characteristics were not found to be a dominant factor. The researchers found that members of most interdisciplinary teams perceived themselves as working well together.

Researchers from Abt Associates Inc.¹⁰ evaluated team processes and perceptions as an operational factor influencing positive outcomes, with similar results. In this study, researchers observed three interrelated factors that are linked to positive components of care management in PACE: (1) operational factors; (2) resource factors; and (3) effective management of operational and resource factors. Team processes were categorized under operational factors and the authors concluded that more mature interdisciplinary teams had “greater depth, creativity, proactivity, and flexibility in their problem solving and tended to focus much less of their time and energy on logistical issues.” The results suggest that better interaction and cohesiveness of the team are influential over care management and may lead to better outcomes.

Similarly, Mukamel et al.¹⁷ observed that programs with more effective teams had better outcomes after 1 year of service than their counterparts. Therefore, interdisciplinary professionals working as a cohesive and comprehensive team developed and implemented better care plans and coordinate services for better care. The report found that comprehensive, empowered teams achieve more complete assessments of needs, and the authors encourage input in care planning from those involved in its implementation.

At PACE, the individualized care plans developed by team members often emphasize independence and build on enrollees’ strengths and qualities. Enrollees are encouraged to adhere to this plan of care as a way to maintain an optimal level of health and functioning. Problems, goals, and interventions are assigned to their respective disciplines for follow-up and are revised every 6 months or after a major change or event. The interdisciplinary team’s ability to integrate and carry out all disciplines as laid out in the plan of care, rather than the plan of care itself, may be the critical factor in reducing hospital admissions and improving outcomes.⁶  

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The Role of the Adult Daycare Center
Adult daycare centers are the foundation of PACE operations and are where most services are provided and where the interdisciplinary team convenes.¹⁸ Temkin-Greener and colleagues¹⁹ observed an association between daycare center attendance and frequency of hospital admissions. This may be related to the fact that the interdisciplinary team members promote preventive care measures while at the center. For example, enrollees are offered vaccines, reminded of medical appointments, encouraged to go for specialty consults, and receive services from a variety of providers who visit the PACE center, such as dentists, podiatrists, and psychiatrists.

At the very minimum, enrollees are encouraged to attend the center at least once a month for a clinical check-up,²⁰ and some enrollees see the provider more than once a month. The majority of enrollees attend the center several times a week, where they benefit from socialization, recreational activities, and meals.²¹ Transportation is provided, making it relatively easy for enrollees to travel to and from the center.²⁰ However, those individuals not attending the center on a regular basis may be offered services in their home. The interdisciplinary team may choose to place an enrollee on the home-bound list, meaning that visits to the center will be limited and that some members of the interdisciplinary team will visit an enrollee’s home to assess their status at least once per month.

At many sites, the effective integration of clinical, social, and recreational activities leads to a better flow of communication and better opportunities to assess needs. For example, an enrollee who is observed by a center aide to have difficulty eating lunch is referred to the dietitian for evaluation, who might consult with the primary care provider for referral to a speech-language pathologist for a swallowing study. Early intervention at the PACE center, in situations like the one described above, decreases the need for a hospital visit later on, as opposed to an event occurring at home where it might not be observed right away or receive the appropriate intervention.

Variations on the PACE Model of Care
Although highly popular among long-term care and managed care experts, the PACE model of care is not without limitations. Although the model and programs are exemplary in reducing hospitalizations and early institutionalization among older adults with MCCs, PACE has not exhibited the program growth initially expected.²² Lynch and associates²³ researched the stagnant growth of the program and concluded that the adult daycare center and switch of primary care providers were not appealing to many older adults who preferred to receive services at home and continue to see their own primary care physicians.

Nonetheless, the PACE model of care has appeal and applicability beyond PACE programs. There is a demand for models of care that improve outcomes and reduce expenditures. Hybrid models of PACE²⁴ have emerged in which PACE core practices are incorporated along with measures to mitigate PACE limitations. For example, in 2002, the original On-Lok organization modified their model by expanding services to use a community physician model. A similar initiative is the Geriatric Resources for Assessment and Care of Elders (GRACE) model, which was established for the same purpose as PACE: to increase functional status and decrease hospitalizations among older adults with MCCs. The GRACE model supports an enrollee’s existing primary care provider through an interdisciplinary team that includes a geriatrician.²⁵

The Wisconsin Partnership Program (WPP) is also a variant of PACE that does not require adult daycare center attendance and allows enrollees to choose their primary care provider, as long as the provider agrees to serve as a partnership member. WPP has been noted to produce outcomes similar to those of PACE.²⁴ Furthermore, the WPP model may have applicability beyond the United States.

The older adult population is also increasing in other parts of the world, and the United States is not the only country experiencing difficulties providing long-term care solutions for this growing population. Keong and associates²⁶ studied the Singapore Program for Integrated Care for the Elderly (SPICE), a long-term care program modeled after PACE that has been successful in reducing more than 50% of hospitalizations, length of hospital stay, and emergency room visits among their enrollees. Their findings, although limited, could mean that PACE replications can be successfully implemented in other countries, despite differences across social cultures or systems for healthcare delivery.

Healthcare payers and providers would benefit from knowledge of the PACE model of care, its core practices, and its limitations. The model could be applied beyond the current PACE program approach (ie, hybrid or customized programs) and in countries experiencing a shortage of long-term care options for older adults with MCCs.

Recommendations for Policy and Practice
Healthcare payers and providers should take the PACE model of care into consideration for the advancement of new and inclusive health policies promoting management of MCC and reduction in use of inpatient hospital services. Whereas expansion of the PACE program itself is important, the model could continue transcending the barriers imposed by federal regulations and statutes to reach older adults who are not at the nursing home level of care, or who do not live in a PACE serviceable area. The current eligibility criteria require that enrollees be certified by their state to meet nursing home level of care needs and be 55 years of age or older. This is a disadvantage to adults younger than 55 years of age with MCCs who may also benefit from a team-based model of care. Furthermore, the requirement for an individual to be dually eligible for Medicare and Medicaid is a limitation, as the model could operate well under either of the two programs alone.

Healthcare providers can incorporate the PACE model into their private practices by partnering with community organizations and other providers around the area. For example, now that adult daycare centers are popular in many urban settings across the nation, physicians and independent providers can partner with these centers and their staff to provide more cohesive and integrated care. Many adult daycare centers already have nursing, social services, recreation, and dietary services and only lack the primary care component. Through a simple partnership, community physicians may be able to reduce hospitalizations among their patients and at the same time improve their quality of life.

Conclusions
In the United States, because PACE programs operate under unique federal statutes and regulations, expansion or incorporation may not be an immediate solution for community-based providers. However, it would be advantageous to incorporate some of the model’s core components—such as the interdisciplinary team—into private practices, in a way similar to that of the Patient-Centered Medical Home, the Assisted Living Model, or other home- and community-based services programs. Many healthcare organizations could greatly benefit from an interdisciplinary team of healthcare providers promoting comprehensive care across the continuum as well as the model’s demonstrated ability to prevent unnecessary hospitalizations among individuals with MCCs.

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