Keeping Up the PACE:
Care for Older Adults in
our Communities

According to the 2022 Uniform Data System (UDS), the senior population in community health centers has experienced significant growth with an increase of more than one million patients in the last five years. Caring for an increasing older population is a challenge facing many health centers who are looking for innovative care strategies to address this population's complex needs.

“We wanted to make sure that our seniors would have the health care in their community so they can continue living at home rather than go into a nursing home,” says Brian Toomey, CEO, Piedmont Health, Chapel Hill, NC, one of the early adopter health centers offering PACE (Program for All Inclusive Care for the Elderly). “At our core is the belief in providing the right care, at the right time, at the right place, and done right. This is our “WHY” for creating, investing in, and growing our PACE organization,” adds Toomey. He encourages any health center considering starting a PACE to be very clear on their “WHY.” This is what will drive the health center and keep it centered.
What is PACE? 
PACE is a national program providing a comprehensive package of services that help low-income adults aged 55 and older who need nursing home care, to successfully remain in their homes for as long as possible. It provides services that encompass all aspects of a PACE participant’s health care including high-quality preventive, primary, acute, and long-term care and social services such as medical transportation, implementation of safety measures at home, and meal delivery.
Becoming a PACE Organization—Opportunities and Challenges
“We have always cared for and loved these patients long before they were eligible for both Medicare and Medicaid benefits, and other health systems wanted them as patients,” says Vernita Todd, Vice President & Chief Strategy Officer, San Ysidro Health, whose San Diego PACE serves an average of 2,622 participants each month across four sites. “While we recognized we had a pipeline of patients who could be eligible PACE participants, we also knew that we were a trusted health partner to many of them. We wanted to make a commitment to them to continue to provide care as they age and their care needs became more complex.”

Toomey and Todd whose health centers have been PACE organizations for more than ten years believe that PACE offer health centers several unique opportunities and challenges:

  • Know your health center’s “WHY” for starting a PACE to keep you focused.
  • Understand the difference between capitation and fee for service (which is what health center providers, staff, administration, and leadership are trained in).
  • When operating in a risk-based environment, give careful consideration to providing care for people in the right way, rather than how much you get paid for performing the care. 
  • Managing utilization of services is a priority concern in a risk-based environment.
  • As a health insurance plan and provider, you must create a system of checks and balances for care plans, so a participant’s care services are not over or underutilized. 
  • PACE has a ratio-based staffing model. Understand the ratios by category and be prepared to be fully staffed at every level and type of care service from day one. 
  • Make sure processes and systems for managing many PACE components, such as meal delivery, are scalable.
  • Try to make systems more automated and less manually-driven when possible.
  • PACE can be very profitable. However, it does require an upfront capital investment and operational funds. 
Looking to start PACE? Do your research.

  • Understand your state’s PACE landscape. Learn your state rules and if PACE is approved. Every state is different. 

  • Do PACE organizations currently exist in your state? If so, talk to them about possible partnership opportunities, rather than starting one. 

  • Talk and visit with other health centers that have PACE. Include staff from across your organization – board, leadership, medical, pharmacy, behavioral health, etc. 

  • Download resources and participate in trainings from PACE@CHC, a program to help health centers develop a better understanding of the PACE model.

Urban Health Plan’s Center for Healthy Aging – Giving Specialized Care and Extra Support Services to Patients Aged 80+ and their Care Givers 

A successful care management program for patients 65 and older laid the foundation for Urban Health Plan, Bronx, NY, to create a specialized care program to meet a growing new patient population: the very old – those adults 80 years and older. In 2016, the health center’s Center for Healthy Aging opened its doors to these patients, as well as those living with a cognitive impairment such as dementia or Parkinson’s disease. 

“We built the space conducive to this population (i.e., hand railings, scales to weigh wheelchair-bound patients) that really became their very own space. This included conducting focus groups with these patients to ensure their perspectives were captured,” explained Paloma Izquierdo-Hernandez, President and CEO, Urban Health Plan. “We wanted it to be an interdisciplinary approach. In addition to primary care and lab services, we offered such specialties as psychiatry and podiatry, so patients did not have to even leave the Center’s dedicated floor to get this care,” she added. Providing social supports for patients and caregivers is core to the Center’s approach.

The interdisciplinary team receives extensive training in caring for, and communicating with, geriatric patients. Since staffing is such a critical component, only staff who want to work with this population can work in the Center. 

To help transition eligible patients to the Center, Urban Health Plan started with one clinician who had many patients aged 80 and older. This clinician saw patients one day a week at the Center. These patients were able to maintain continuity of care with their primary care clinician while receiving the Center’s other medical and social support services.  

“We created our program and outcome evaluation measurements from the ground up. They were designed to provide our interdisciplinary team with the guidance to design an informed and specialized plan of care for each patient and help keep them as healthy as possible and in the community,” said Debbie Lester, Chief Quality and Social Impact Officer, Urban Health Plan. 

The evaluation model contains several preventative screenings, social support assessments, and clinical care monitoring. These measures include risk assessments for nutritional needs, fall risks, and activities for daily living; flu and pneumococcal vaccine reporting; and hypertension, diabetes, asthma control monitoring. Continuity of care measures, such as seeing a primary care clinician three times a year and the timing of these visits, are also tracked.  

Today, the Center for Healthy Aging serves 1650 patients annually and an additional 130
patients who participate in a medical home visiting program. Urban Health Plan would like to grow the Center and is seeking to become a PACE organization, which will help expand its capacity. It is also exploring ways to support end-of-life care, such as hospice. Urban Health Plan continues to shape and plan for the Center’s future with a driving force to not just provide highly integrated care, but to do so with the dignity, sensitivity, respect, and love their patients living in their last stages of life deserve.
Join NACHC’s Subcommittee on Aging
Applications Now Open through Oct. 14, 2023

“Health centers’ aging populations are becoming a larger part of our work and need our services. Medicare utilization continues to grow year over year, and health centers can offer that continuity of care for these patients. As recent Chair of NACHC’s Subcommittee on Healthy Aging, we have discussed issues impacting the aging, but we need more voices and a wider representation from Board members and clinicians. I hope that as the opportunity for committee registrations is now open, that more will seek to join to help us shape health centers as providers of choice for Medicare and aging populations for the future.”

—Kimberly Mitroka, President and CEO, Christopher Rural Health Planning Corporation, Christopher, IL

Learn about the Healthy Aging Subcommittee and other NACHC committees and apply to join a subcommittee at https://www.nachc.org/about-nachc/committees/.
OUR AGING COMMUNITY: Creating a Welcoming and Safe Environment
Mindfulness & Relaxation—Anywhere, Anytime.

Looking for mindfulness and relaxation techniques to help manage and ease anxiety at a moment’s notice? Check out these apps and download one you think can help clear your mind and reduce your anxiety anywhere and anytime. 

Breathe2Relax—This app teaches users how to manage their stress through guided breathing. Find the app in the Google Play Store and in the Apple App Store.

Anxiety Solution—This app offers a toolkit that includes interactive breathing tools and over 70 mindfulness, meditation, sleep stories, and fitness routines to help manage anxious thoughts and behaviors. Find the app in the Apple App Store.

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