Causal Evidence From Nonparametric Bounds
Improving Care for Older Adults
Leveraging Comprehensive, Community-Based Care Programs To Improve Care for Black and Latino Older Adults
The Program of All-Inclusive Care For the Elderly (PACE) Model Provides More Equitable Health Care While Helping Keep People in Their Communities
Many older adults who qualify for Medicaid, are 55 years of age and older, and live with disabilities have the cost-free option of enrolling in a so-called PACE program. Short for the Program of all-Inclusive Care for the Elderly, PACE offers community-based care and services to nursing home-eligible older adults so that they can continue to live in their communities. Individuals enrolled in PACE receive comprehensive, coordinated health and social services, including prescription drugs, doctor care, transportation, home care, check-ups, and hospital visits and nursing home stays when necessary.
PACE isn’t available everywhere, but its availability is expanding (~55,000 enrollees in 144 programs across 30 states). In areas where it’s an option, enrollment in PACE has numerous benefits. As intended, most individuals who opt into the program are able to live safely in their communities and stay out of nursing homes. Studies have shown that, compared to individuals who opt out of a PACE program, those who choose PACE not only have fewer and shorter nursing home stays, but also decreased rates of hospitalization, greater overall survival, lower rates of depression, and increased social interaction.
What enables PACE programs to consistently deliver high quality, equitable care to older adults? The answer: it’s the payment model. PACE programs offer a comprehensive, coordinated set of health and social services that enable nursing home-eligible older adults to continue to live in their communities. To achieve this goal, PACE programs receive monthly payments from Medicare and Medicaid to cover the entirety of the care for each member, enabling a focus on prevention of costly and often avoidable hospitalizations and nursing home admissions.
Still, despite the proven advantages of PACE, many older adults who qualify for PACE and live in a PACE-covered area do not enroll in the program. We wanted to learn the reasons why. We were particularly focused on Black and Latino older adults, who have seen a disproportionate rise in nursing home use.
As we reported recently in the Journal of Aging & Social Policy, our team examined how Black and Latino older adults engage with PACE programs and what facilitated or impeded their access to and enrollment in PACE programs. Our findings revealed both facilitators and barriers to enrollment in a PACE program.
- Information highlighting the benefits of PACE: Potential enrollees and their caregivers need information that assures them that the program provides high quality care. They valued the fact that PACE focuses on independence and person-centered care. PACE enrollees also appreciated that PACE provides a one-stop shop, including access to transportation, pharmacy, and health care providers.
- Social connections: Potential enrollees and their caregivers valued social connections with other members and staff, as well as the community nature of the program.
- Poor information dissemination: Many Black and Latino older adults and their families were unfamiliar with the program. A lot of knowledge about PACE occurred via word of mouth, but there were concerns around not hearing about PACE from other sources such as their primary care provider.
- Lack of trust: Many individuals who qualified for PACE said that when they learned about the program, it felt to be too good to be true. This was particularly the case because PACE provided all of its services to Medicaid eligible enrollees without any cost to them (e.g., prescription, transportation, co-pays).
- Inaccessibility of PACE: Cost of PACE was identified as prohibitive for those who do not qualify for Medicaid and cannot comfortably pay a monthly premium. It has been reported that Medicare-only recipients need to pay as much as $4400 a month out of pocket to subsidize PACE services not paid through Medicare and additionally purchase prescription coverage through Medicare Part D independently which costs more than $800/month.
- Concern about losing a trusted, long-standing primary care provider: Some were reluctant to enroll because of the program requirement to give up their primary care provider.
- Insensitivity to differences: Potential enrollees reported that staff at some PACE programs were inadequately sensitive to enrollees’ cultural and disability differences and lacked cultural diversity. PACE programs also lacked interpreters and recruitment materials in the languages of some potential member and their family caregivers.
These findings point to potential strategies that may increase access to PACE and decrease inequities in the quality of long-term care—such as improved communication about the program, provision of culturally appropriate materials, engagement with community health care providers and local aging organizations and expanded access to PACE program, beyond Medicaid beneficiaries.
Such efforts are more than worthwhile given the growing older adult population in the United States. The success of PACE offers policymakers strong evidence for a funding mechanism and program that holds promise for broader application in more communities across the United States. We hope that these findings will help guide future steps to reduce barriers and enhance access to PACE programs by older adults from racial and ethnic minoritized groups and all other eligible older adults.
The study, Minority Older Adults’ Access to and Use of Programs of All-Inclusive Care for the Elderly, was published in the Journal of Aging & Social Policy on February 7, 2022. Authors include Jasmine Travers, Sara D’Arpino, Christine Bradway, Sarah J. Kim, and Mary D. Naylor.
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