Mary Jefferson (left) works on jewelry making with certified nursing assistant Angela Moore at the Riverside PACE center in Manchester. Sarah Walor photo
Despite depictions of active retirement living, the face of aging does not always resemble the baby boomer celebrity on the cover of AARP magazine. Thousands of elderly Virginians with complex ailments struggle with basic daily activities, some that strain even their caregivers.
Although these senior citizens qualify for the level of care provided at a nursing home, they cling to the comfort and familiarity that is home. Programs for All-inclusive Care for the Elderly, or PACE , responds to that need and desire with a goal to stabilize or improve the health and well-being of the frailest members of this population, who often are the most costly to serve, and enable them to remain safely in the community and avoid more expensive institutional services.
"I needed the program. I needed what it offered," says Mary Jefferson, 89, who feels more at home in the Riverside PACE program after about a year and a half than she does in her church, which she joined 75 years ago. She lives with her daughter in Richmond but embraces PACE for the chance to socialize, contribute to the newsletter and learn new subjects. "It's the place to be for poor people like me. I call this my mobile nursing home," says the retired Wachovia employee who does not want to be a burden on family and friends but is "just not well" after a stroke and several surgeries. On good days, she uses a walker for mobility. "I don't need a lot of things, but the things I do need, I need badly."
Just four years after its formal introduction in Virginia, PACE operates in eight locations run by five health care providers. Another eight PACE sites are under development. Riverside Health System, a Newport News-based provider of medical and wellness care, runs two programs in Richmond from centers in Manchester and Scott's Addition. A location on Brown Avenue in Petersburg is under development.
"PACE is innovative and a significantly enhanced program that changes the way in which services are provided to the elderly," says Craig Markva, spokesman for the Virginia Department of Medical Assistance Services, which administers Medicaid for the poor. "It provides for coordinated, integrated, comprehensive and holistic care for the individual in their homes and communities. … It is a cost-effective model that meets the needs of the citizens of the commonwealth."
States are looking for relief as the Medicaid portion of their budgets grows, the Northern Virginia-based National PACE Association notes in its literature. In Virginia, the elderly make up 8 percent of Medicaid recipients but are responsible for 18 percent of program expenditures, according to the state. Nearly all PACE participants receive both Medicaid benefits for long-term care (generally after spending down their assets) and Medicare benefits for medical expenses.
The program provides weekday transportation to and from the participant's home to a PACE center for physical and mental activities and socialization, occupational and physical and speech therapy, primary medical care, breakfast and lunch, pharmacy services, bathing, social work, and spiritual counseling, as well as memory care for about half the participants, and other services that extend to home care, rides to medical specialists, and conferences with families or caregivers to ensure the participant's safety and wellness. The enrollee, the caregiver and an individual care coordinator discuss and assess needs, plan for holistic care involving the interdisciplinary team, and collaboratively update the plan several times a year. Local participants must be 55 or older, live within a 60-mile radius of Richmond, qualify through an independent assessment that they need a nursing home level of care, and be able to live in the community with the support of PACE.
The 30-year-old PACE concept gained a foothold in Virginia in 2007 when then-Gov. Tim Kaine, through the Department of Medical Assistance Services, made seed funding available for five PACE sites, including Big Stone Gap and Cedar Bluff, two of the earliest rural PACE locations in the nation.
The average PACE enrollee is 78 years old, takes a half-dozen medications, has five chronic diseases, and experiences difficulty with some activities, such as eating, bathing and dressing, says Kelley Barnes, director of the site at East Sixth and Gordon streets in Manchester's industrial area. The building formerly served as a trash-truck assembly plant and a cast-iron stove factory. Some participants experienced their first full-body bathing in two to five years upon enrollment, Barnes says. "Hygiene is important. You need it for proper health. It's a dignity issue, and once clean and in fresh clothes, they feel better about socializing."
Riverside PACE rehabilitation director Rebecca Edwards talks about the importance of keeping participants as mobile as possible for independence. "Mobility, that's the deal breaker when caregivers can't manage these people at home," she says. For that reason, PACE holds activities in different rooms and allows participants full run of the building. Tags that staff members attach to the back of participants' collars sense when a person gets near certain doors and automatically lock the door for the participant's safety.
Combined, the Richmond sites served 155 people with a staff of about 175 in early August, a month after the opening of Riverside PACE's largest location, a 33,000-square-foot site with 13 independent living apartments on MacTavish Avenue in Scott's Addition. A fitness center at the site is called the Cavalier Arena in honor of its former use as a roller-skating rink. At capacity, the programs will be able to accommodate 320 people.
In January, the six existing programs served about 650 Virginians. They were among 75 PACE sites in 30 states that assisted 23,000 people. Researchers have found PACE participants have fewer hospital and nursing home placements, improved health status and an enhanced quality of life.
"We like the program," says David DeBiasi, associate state director for advocacy at AARP Virginia. "It has good consumer satisfaction and is one of several models for integrated care. PACE participants live longer and spend more days in their community."
Steve Morrisette, president of the Virginia Health Care Association, says the membership organization of 275 long-term care facilities thinks PACE does a great job. "They certainly are an alternative to nursing home care and allow for people to be cared for at the level they need. But they also have contracts with nursing homes when people need them."
Virginia has 23,000 nursing home beds, just about all of them for the frail elderly, and for about 18,000 Medicaid recipients in long-term care, he says.
Craig Connors, who started PACE for Riverside with its Hampton location, says roughly 20,000 people in Virginia and about 4,000 in Riverside's Richmond service area qualify for PACE and live in the community (versus in a nursing home). The numbers would more than double if the population included people living in nursing homes and those who have not been determined as eligible, but probably would meet the qualifications.
"I am a big fan of PACE," says Dr. Peter Boling, professor of geriatric medicine at Virginia Commonwealth University Medical Center. In the 1980s, he visited the original site in San Francisco where the PACE model was developed. VCU geriatrics is providing medical care at the Richmond PACE centers. "PACE is a very rich service model for patients. It is a supportive model for the professional team. Its only limitation is size. … We have several thousand people in Richmond with these kinds of complex geriatric needs. So PACE right now is only a part of the answer."
The 65-and-older population will explode in the Richmond region in the next 20 years, more than doubling from 2010 numbers. The 115,000 elderly adults in seven nearby counties and Richmond are projected to soar to 232,000. In New Kent County, that segment of the population could grow more than three times the 2,300 current estimate to about 7,600.
So why isn't PACE more prevalent?
"It has to do with how health care was set up. It's more payer-friendly," says DeBiasi of AARP Virginia. "Health care reform is going to incentivize the team approach … that looks at treating the whole person" and promoting wellness.
"What separates us from other providers is that their responsibility stops and starts," says Robert Greenwood, a spokesman for the National PACE Association, citing Meals on Wheels as an example. "We serve the entire person, from nursing homes, end-of-life care, transportation, clinical and financial incentives. We're not restricted to providing the services that only Medicaid and Medicare provide for. In the South, we see a lot of congestive heart disease. We can provide air-conditioning units for our participants' homes that will slow their rate of decline, versus services only for the improvement of a recipient's health."
Even primary-care doctors who could lose longtime patients to PACE's physicians see a potential upside.
"There's a shortage of primary-care doctors across the country, and generally elderly patients are among the most complex cases. Their care takes a lot of time for the same reimbursement," says Dr. Joseph "Jay" Galeski, who has practiced in the Richmond area for 30 years and adds that he has heard no concerns from other doctors about losing patients to PACE primary-care physicians. "I love the older, complex patients, but for the past five or 10 years, I haven't been able to take on additional patients because of the ones I have. I think most doctors don't want to lose patients, but with the business model we're currently in, they are the more difficult patients."