Intensive program keeps elderly at home, out of nursing home

Almost no one opts for a nursing home over the comforts of home. Elderly patients enter such nursing facilities because they’re left with no other choice, given the levels of care they need. And even if a family manages to dodge the pervasive problem of substandard care, nursing homes are extremely expensive.

But what if frail elders – patients who would otherwise be forced to enter nursing homes – could find a way to stay at home while still getting the extensive care and services they need? That’s the idea behind the Program of All-Inclusive Care for the Elderly, or PACE, a Medicare program and Medicaid state option that provides community based care and services to people age 55 or older who otherwise would need a nursing home level of care. 

In Los Angeles, the large not-for-profit AltaMed, a federally qualified community health organization, provides extensive care for 1,700 patients at eight PACE sites throughout Los Angeles County, with Latinos and Asians making up the majority of the organization’s patients.

“Everybody in PACE is nursing-home eligible, meaning Medi-Cal would pay for them to be in a nursing home, but that’s a very expensive place to stay,” said Dr. Martin Serota, AltaMed’s chief medical officer, speaking to a group of fellows who toured the organization’s El Monte program this week. “So everyone of those patients could be in a nursing home, although only 6 percent of them are, in our hands. So we’re successful in keeping 94 percent of those patients out of the nursing home, and that drops the cost exponentially.”

About 20 doctors care for about 1,700 patients in AltaMed’s PACE program, far fewer patients per provider than usual. That ratio allows providers to spend far more time helping each patient. “That’s one of the most important pieces of how we manage our patients so closely,” said Dr. Esiquio Casillas, AltaMed’s regional medical director for senior services.

On a Tuesday shortly before noon, seniors in the El Monte program filled tables in a large room, waiting for the next bingo number to be called. Lunch would soon be served, and if anyone needed to visit his doctor, pharmacist or physical therapist, a short trip down the hall would get him there. In an exercise room, physical therapists helped some strengthen motor skills to ward off falls. On another day, there might be a celebration of a religious holiday, live music or a crafts fair. Drivers shuttle the seniors from home and back. The idea is to keep the residents as engaged, stimulated and socially connected as possible. Doing so helps ward off depression and keeps them healthier.

A 14-member interdisciplinary team coordinates each senior patient’s care. The team includes a doctor, pharmacist, physical therapist, nurse, social worker and driver, among others. Depending on the person’s diagnosis, AltaMed’s reimbursement varies from $2,000 to $6,000 per patient per month, according to Casillas.

The approach behind PACE dates to the early 1970s, when On Lok, a nonprofit catering to elderly immigrants in San Francisco’s Chinatown and North Beach communities, began offering adult day care, in-home care, medical care and social services. From that early seed, PACE has since grown to 108 centers in 32 states. To participate, seniors must be low income, state-certified as eligible for a nursing home and live in the service area of one of the programs. All of the patients are covered by MediCal, and most by Medicare as well.

Starting a PACE can be exceedingly difficult. Casillas says it took AltaMed several years and a multimillion-dollar investment to launch its program. That barrier to entry may be prohibitively high for some, but Casillas says AltaMed considers the program a success, a sentiment borne out by data on several key quality measures.

“Even though we have very sick patients, they go to the hospital quite a bit less – even less than patients who are not as sick,” Casillas said. Since hospital stays tend to be extremely expensive for PACE patients, catching those problems before patients end up in the hospital can save the government a lot of money over time.

“The highest cost in Medicaid is paying for long-term care for patients to live in a nursing home,” Casillas said. “This is really the area that you want to focus on, keeping people healthy in the community — not only because of costs, but because obviously most patients don’t want to live in a nursing home.”