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What can hospice offer to PACE sites?
Philosophies similar; opportunities may be limited
By Larry Beresford
One of the more intriguing prospects for hospice’s participation in a broader continuum of palliative or end-of-life care is collaboration with PACE (Program of All-Inclusive Care for the Elderly) sites. PACE is the federal program created to clone San Francisco’s legendary On Lok Senior Health Services program. The possibilities of working with PACE sites, along with some real-world examples, were highlighted at the recent conference of the Alexandria, VA-based National Hospice and Palliative Care Organization, held in September in Phoenix.
PACE dissemination nationwide has been disappointingly slow, despite consistent federal encouragement, elevation in 1997 from demonstration to permanent status under Medicare and Medicaid, and additional legislation passed in 2000 to expand its opportunities for growth. Today there are 37 operational PACE sites across the country, with others in various stages of development. It’s projected that there will be between 50 and 100 functioning sites within five years, according to Shawn Bloom, executive director of the National PACE Association in Washington, DC.
PACE and hospice: Parallel tracks
Presentations at the Phoenix conference emphasized the complementary philosophies of comprehensive, coordinated end-of-life care practiced by hospice and PACE, which developed on parallel tracks in the early 1980s. If anything, PACE is even more holistic, coordinated, and team-oriented than hospice, with a determination to maximize independence and quality of life for the frailest elderly participants.
PACE has an impressive track record of keeping such clients in their own homes and communities and out of hospitals, emergency rooms, or nursing homes. Nationally, about 20% of PACE enrollees die each year, so the program has plenty of experience in providing end-of-life care.
"Philosophically, PACE and hospice could be wonderful partners, but realistically, what are the opportunities for this actually happening on a widespread basis?" Bloom asks. Other observers see the potential for innovative collaborations, although on a fairly limited scale.
What is On Lok?
The PACE prototype, On Lok (Cantonese for "peaceful, happy abode"), began in San Francisco’s Chinatown in 1971 as an adult day health center. Home care services were added in 1975, federal demonstration project status in 1978, and a unique Medicare/Medicare waiver in 1983, making On Lok true one-stop shopping for all medical, rehabilitative, social, and supportive services needed by the frail elders under its care.
Today On Lok serves a culturally diverse caseload of nearly 1,000 clients, with an average age of 82. Based on its long success at keeping them in the community, the federal government began supporting research on the model and how to replicate it, leading to authorizing legislation for PACE, which passed in 1987 and 1990.
Clients eligible for PACE must be 55 or older, residents of the site’s service area, and certified by the state Medicaid agency as frail enough to need nursing home-level care. In exchange for providing and coordinating a comprehensive range of acute care, long-term care, and supportive services (including all Medicare- and Medicaid-covered benefits), the PACE site receives monthly capitated payment from Medicare and Medicaid (current combined rate is about $3,800, regionally adjusted). Most PACE clients qualify for both Medicare and Medicaid, but a smaller proportion pays out-of-pocket for either or both components.
Adult day care is an essential centerpiece of PACE sites, and primary medical care is provided by physicians on staff. The structure is so comprehensive and coordinated that it can be difficult to pull together all of the pieces required for a successful PACE application, which is reflected in the small number of operational sites.
The components of a successful PACE site include consumer advisory committees, geriatric-experienced staff in a number of disciplines, dental care, and demonstrable financial stability and reserves. It is often said that the driver who brings participants to the PACE center every day is one of the most important members of the team and a key informant regarding what’s going on in the client’s life.
Privately funded and federal demonstration grants are now trying to encourage greater participation by for-profit and rural PACE sites as well as statewide coordinating efforts. The current crisis in state Medicaid budgets is a major barrier to PACE expansion, Bloom says, but in time could encourage wider use of the demonstrably cost-effective program.
How PACE can work with hospice
There are several ways for hospices to work with PACE sites, he notes. However, it is not realistic for hospices to expect PACE sites to refer their dying patients on a widespread basis for hospice’s all-inclusive approach and per diem reimbursement. Such referrals would require the PACE site either to disenroll them from PACE or else directly pay the hospice’s per diem under contract out of its capitated rate.
PACE participants are enrolled, on average, two or more years prior to their deaths, and by the time they have a prognosis of six months or less to live, they have established relationships with the PACE team and their primary care physician, who have confidence in their ability to manage the terminal phase of care, as well.
Recent Medicare memorandums have confirmed that PACE’s care management responsibility includes end-of-life care, but purchasing specialized palliative care consultation services from a certified hospice would be permitted under Medicare rules.
Referrals from PACE for hospice care would be the occasional cases where the patient’s need could not be met any other way, where hospice’s end-of-life expertise was particularly needed, or at times of peak capacity. A better bet for the hospice might be to work with a new PACE site with less end-of-life expertise and resources. More promising is for the hospice to offer unbundled palliative care or bereavement services as needed by the PACE team, Bloom says. A final option is for the hospice to become a comprehensive PACE site. Particularly in rural areas where PACE has not been able to get a foothold, the hospice program already may have the best infrastructure for comprehensive care of isolated frail elders.
"If I were a hospice, I would focus on bringing to bear a set of consultative services in palliative and end-of-life care that can be provided to PACE on an a la carte basis — and be sincere about it," rather than trying to encourage the PACE site to disenroll its patients and refer them for hospice care, Bloom says. Current hospice/PACE collaborations include the following:
• San Diego Hospice is closely involved in the development of a new PACE site proposal by St. Paul’s Senior Homes and Services in San Diego, with plans for the hospice to be a major subcontractor for pieces of the PACE continuum, including medical services provided by its staff physicians.
• In Cleveland, Hospice of the Western Reserve has provided palliative care services to the clients of Concordia Care, an operational PACE site, since 1999. Their contract covers all of the members of the hospice’s palliative care team, as well as its inpatient, respite, and residential levels of care, but most referrals from Concordia are for the hospice’s palliative care nurse, who currently carries a caseload of 22 PACE enrollees.
• Other examples of PACE sites contracting with local hospices for palliative care consultation services include Providence Elder Place in Seattle and ESP North Shore in Boston.
• Hope Hospice and Palliative Care in Fort Myers, FL, is interested in developing its own PACE site, but needs enabling state legislation in order to go forward.
• Midland Hospice in Topeka, KS, which has operated an adult day care program for both hospice and non-hospice clients since 1993, is now developing a proposal to the Centers for Medicare & Medicaid Services to become a PACE provider in its largely rural service area.
"PACE is integrated even beyond what we do in hospice," Midland Hospice executive director Karren Weichert says. "It’s a continuous process of assessment, treatment planning, service provision and monitoring." Hospices should be involved in PACE development, she says, "because it is happening, and it is working. PACE is a good program."
Is collaboration between hospices and PACE sites viable? "You have to go back to the question: Can the mission of hospice support it?" notes Judy Bartlett of Hospice of the Western Reserve in Cleveland. "It’s not a money-making endeavor for hospice to work with PACE. But if the hospice’s mission is to provide excellence in palliative care to the entire community, and its core values are aligned with the PACE program," then collaboration could make a lot of sense.
On Lok, the flagship PACE provider, refers about 10 terminally ill clients per year to local hospices out of its caseload of nearly 1,000. In most cases, the On Lok team is fully committed and qualified to care for clients dying at home, says On Lok’s executive director, Jennie Chin-Hansen.
"Hospice is well known for its synchronized, compassionate care. I think that’s also what we offer. We also become part of their family, but at an earlier stage of the illness." The richness of the relationship between the client and the team is what enables On Lok to manage its patients’ care up to the point of death, she explains. "We’re not about unnecessary heroics. On Lok was built from early on with the commitment to be there for the whole nine yards. And most of our clients choose a comfort-care approach."
The team makes it a priority to assess and establish the client’s care preferences and lifestyle choices right from the beginning. "We bring in the family and try to do some preventive engagement, such as establishing who’s going to be the decision-maker or have durable power of attorney, before the point of crisis," Chin-Hansen reports. "We may not be quite as specialized as hospice, but it seems like the core services are captured by this approach," including the concept of dignity and a focus on comfort care and pain management.