PACE-Program of All-Inclusive Care for the Elderly-was introduced to North Carolinians by Wilmington's Elderhaus10 years ago. To mark the anniversary, Elderhaus PACE holds an Open House this Saturday from 10:00am-2:00pm.
The PACE center is at 2222 S. 17th Street, across from New Hanover Regional Medical Center. This Open House provides an opportunity to view the facilities, meet the staff, learn about the program, and even have health screenings. Children's activities will be outside, including games and face-painting.
Elderhaus CEO Steve Hess and PACE Center Manager Ashton Andrews joined us to talk about the program and the Open House; listen above and see our extended conversation below.
See the North Carolina Legislative Report about PACE here.
Ashton: Elderhaus started approximately 30 years ago, as an adult day center. So a lot of folks know our Elderhaus program as down by Greenfield Lake. It has been there for a number of years and, and runs an adult day center for anyone over the age of 18 who needs day center services or day center health services.
Gina: Does that mean someone who needs observation or assistance, can't be left alone?
Ashton: Yes. So somebody who can't be left alone, perhaps they have traumatic brain injury or a form of dementia, memory loss or cerebral palsy, they might have different conditions that their loved ones may still need to work, but they need assistance.
So our Elderhaus started as an adult day center and then 10 years ago we opened up a PACE program which is a federally and state funded program. The acronym stands for Program for All-Inclusive Care of the Elderly.
The PACE program is for those 55 and older who would be eligible to live in a skilled nursing facility. So they meet the requirements needing what are called activities of daily living; bathing, dressing, feeding. Um, however they do not want to live in a nursing facility. They want to live in the home. And with our services we can do that safely. Then we maintain them in the home and out of nursing homes.
Gina: The adult day center part, that that is a program where people come to you.
Ashton: Yes.
Gina: But the PACE program is in the home?
Ashton: The PACE program is both community and center based services. So in a nutshell, we provide for, for dually eligible folks, Medicaid and Medicare, we provide services both in the home, like aid service. We provide transportation to and from our day center, which is located right across from the hospital on 17th Street. We provide transportation to appointments, doctor's appointments. We provide physical therapy, occupational therapy, whether that might be in the home for somebody who is unable to leave the home or at our center that we have across from the hospital. We provide dietary services. So we have registered dietitians, speech therapy services, we have social workers, licensed clinical social workers as well as registered nurses, nurse practitioners, and medical doctors and physicians who specialize in Gerontology or geriatricians.
Steve: The key with PACE is, we are a health plan that is funded both through Medicare, Medicaid and potentially private funds, paid privately and all-inclusive is everything that you can think of that an individual may need medically. But also it covers a lot of the social aspect of life, you know, the whole movement within healthcare today is moving toward a preventative, proactive approach to healthcare. And PACE is well ahead of the curve. You know, you hear a lot about accountable care organizations, ACOs, managed care. The state of North Carolina in 2019 is going to a dually eligible managed care program. PACE has been doing this for years in the country, we've been doing it in North Carolina for 10 years.
Gina: And the first PACE program in North Carolina was with Elderhaus?
Steve: Yes. And we're very proud of that. That was, you know, the heritage of PACE in North Carolina. It didn't just happen 10 years ago. Um, we had a physician in town, Marshall Fretwell that was the visionary for bringing PACE into the state. She really started this, investigating what PACE was and how it could improve the lives of those that we serve in the community. She started researching that back in the mid nineties, and in really 2002 started trying to get the state of North Carolina to adopt PACE as a model of care. And that finally happened. We opened the doors in 2008, in April 2008.
Gina: So who, who owns PACE? Who runs PACE? Like who is, who's behind PACE itself?
Steve: So PACE is a, as a health plan, PACE is individually owned by each organization that adopts the plan of care. We happened to be a standalone non-profit organization here as Elderhaus, but there are organizations that are large healthcare systems, hospital systems that happened to run PACE programs. There are programs out there that are senior housing that run PACE programs. PACE is a model of care and not and not a specified plan of care. And it really started back in 1970s, early 1970s in San Francisco as a nursing home without walls because in Chinatown there were not nursing homes and there was not- the cost of land was very expensive. and so there was a dentist and a and a social worker that got together and said, "Geez, why can't we do this better? Why can't we, why can't we provide for those in the community instead of sending them across the bay" to nursing homes that didn't know their language, didn't know the customs. And so they, they went to CMS and got, and at that time it was Health and Human Services and got the authority to start a pilot program. Uh, that didn't, didn't really push out into the mainstream until the mid to late eighties when ten other pilots, pilot programs across the country were started. And then in the late 1990s, 1997, it became a permanent option for the very frail elderly in the country.
Gina: So a dentist and a social worker walk into a bar in San Francisco.
Steve: Yeah. What do we do with this? Right?
Gina: I'm always wondering well, who's getting all the money from it? So the PACE program is … do you pay dues to somebody to do this?
Steve: Wel,l we do belong to a national association, so there's a National PACE Association which we pay, we do pay a dues to, but it's not to license the program. It's really in, in support of the programs nationally. So there's some, there's certainly a lot of work that has to happen on Capital Hill to keep PACE funded federally and at the state level. There's a lot of support that has to happen. And so the National PACE Association keeps us abreast of new changes in regulation. They really keep in touch with Capitol Hill, with the Centers for Medicare, Medicaid Services to ensure that they understand the difference in our program versus other healthcare programs. The key is, and it is confusing from the standpoint of everything that we know in this country is fee for service. So it's not uncommon for people to glow after they've been to the doctor a bunch of times because we have x-rayed them over and over and over again, and every time it happens, somebody gets paid. Within the pace program were what's termed a capitated program. So we get x number of dollars for every participant in our program at the first of the month. That money goes into a big bucket. It doesn't follow the person. And we use those dollars to pay for the care of those individuals for that month. Uh, both socially and medically.
Gina: So it's like health insurance, sort of.
Steve: Yes, sort of, kind of maybe, yes.
Ashton: So the interesting part about PACE is that we become both somebodies insurer-so we are, we are given funds by Medicaid and Medicare to provide all the care necessary for that person-and then we are tasks as what's called an interdisciplinary team with determining and doing assessments to determine what is appropriate for each individual. So every individual gets a really individualized care plan, for lack of a better term. They get what they need and not necessarily what someone else needs. And that may mean things like aid service in the home, that may mean someone coming out for bathing and dressing and feeding, that may mean that they may get physical therapy five days a week because they fractured their hip two months ago, but somebody else doesn't need physical therapy so they may not receive that same service. The way the program receives its funds, the state is a “capitated” amount, so a bulk amount at the first of every month.
Ashton: For some individuals, they may pay nothing if they're dually eligible and they make under a certain income. There may not be any co what, what we would think of in the general world as a copay. For some, depending again on their income, there might be a small copay, but there's no copays for medication. There's no hospital bill. Nobody ever gets a bill because they went to the hospital. There is no specialist fee of $40. Um, there's, there really is. It's all-encompassing.
Steve: So yes, and the, the, you know, the other component of that is we are 100 percent responsible. We-
Gina: You as Elderhaus?
Steve: Yes, as Elderhaus, for the care of that individual. And to ensure that we are meeting their, their medical needs and their psychosocial needs at the level that they need it. So on a daily basis we are talking internally, you know, across team members when, when Ashton mentioned the interdisciplinary team, it kind of gets passed over, but is such a critical component of what we do that it is unlike what individuals in healthcare normally see as an interdisciplinary team from the standpoint of, we have a driver representative in that meeting that's talking about "Well, I just picked Mary up today and she didn't, she was different." And so we have an opportunity then to take that to the, to the clinic and say "there may be something going on. Let's take a look."
Steve: The other component that we do that's different than the fee for service world, and again, because we're dealing with the frailest of frail population ... if for instance, they do have an incident that causes them to be hospitalized and then need to go to a rehab, you know, potentially you get physical therapy or occupational therapy, in the fee for service world, you know, once they plateau, they get back to baseline then what you hear is, "well, we have to discharge you from therapy because you're not making any more progress." What they're really saying is, "because you're not making progress, we don't get paid for providing that care to you anymore. So we, we can't do it. We won't do it." In the PACE world, we can start giving you therapy the day we see you stumble and we can stop the day you die.
We are not doing therapy to get paid. We got paid the first of the month. Our goal is to do everything we can to be preventative and proactive to maintain your level of functionality as long as possible. We cannot do anything about quantity of life. Most of the individuals that we care for, we're not going to cure. The diseases they have are, are, are chronic and progressive, but we can change quality of life and if, if we do nothing else but improve the quality of the life of those that have, that have given to us, that allow us to live the way we do today, that's the best blessing we could have.
Gina: So this is kind of the motivation behind the way that you … the reason you provide the care, the goal of providing that you have in providing care, is just totally kind of different than the average situation of going to the doctor.
Ashton: Yes. We are tasked with managing these folks. Right now we have 119 people in our program, um, and we are tasked with, with providing and maintaining their quality of life through the end of their life. So we have folks who are 55 years old and we have a lady. Our current oldest participant in our program is 100. We've had as old as 102. And so we are really tasked with maintaining quality of life for these individuals and for their families. A lot of folks are living with their loved ones, their daughters, their sons, their, their brothers and sisters, their husbands or wives.
Ashton: And we're tasked with managing that person's quality of life through the end of life. And so we do that as Steve said, in a variety of ways. Whether that's physical therapy, just to maintain. If somebody had a stroke and they might have a they might not be able to use their left arm, but if we don't continue to move that left arm, it's gonna, it's gonna get constricted, it's going to get stuck. And so we might do therapy solely to maintain and reduce any pain in that arm after a stroke. Um, we deal, we manage a lot of folks with dementia, various types of dementia. Whether it's Alzheimer's, whether it's a fronto-temporal dementia, whether it's Lewy bodies dementia, vascular, and we're constantly assisting families and understanding what that looks like through that process as well as trying to create the best environment in our center and in their homes.
For somebody that continues with a progressive disease, we also care for folks with Parkinson's disease and a lot of folks who might have a variety of just compounding chronic illness, not one particular illness that, that really kind of knocks them for a loop. And so we are tasked with that quality of life and we do that because we are not tasked with charging for every service we do. We can practice at a different level both from a medical perspective and from a psychosocial perspective because we're not worried about, I got to write up that bill for that service and this service and if I send them here, you know, we can say and have those conversations with people about what's the best for the quality of life for yourself or your loved one and make decisions based on that.
Gina: How does somebody get to be in the program?
Ashton: So we have an enrollment process and um, generally speaking it takes about 30 days from kind of intake to, to enrollment in the program. Um, they would contact our PACE at 910-343-8209 or stop by at 2222 South 17th Street and communicate with any staff member, but our intake coordinator in particular can help through that process. They do have to, again, be 55 and older. Um, and then we can determine, we can go out to someone's home if they can't come to the center, we can go see them in their home and determine whether they meet the eligibility criteria as we talked about, kind of having those activities of daily living deficits, needing assistance with some of their care. And then they are assessed by multiple team members and, and a plan of care, an individualized plan of care is determined for each individual that comes in.
Gina: Does somebody have to be wealthy to become part of this program?
Ashton: Not at all the majority- I mean, I would say 99 percent of our individuals live at or below the poverty level.
Steve: Yeah. We have the majority across the country, the majority of PACE participants are what we would term as dual eligible. So their Medicaid and Medicare eligible. And what that does is it really is taking not only the frailest of frail population, but it's also taking that population that may be lower socioeconomic, that has not had access to healthcare like those wealthy individuals that live in our communities have. You know, the, the other thing that we're, that we do and that we're very proud of is, when you become a caregiver for your loved one, if you're the son, daughter, husband, wife, you are taking on a different role and you're no longer the son, daughter, husband and wife. You're the caregiver and you're on 24/7. And so what we do is we step into those care giver shoes with the caregiver and as a partnership now, we take all of this on.
Steve: So we give that caregiver respite time to recharge, uh, to become the son, daughter, husband and wife again, to be able to love their loved one at the level they can, to see them where they are. And then we help. We help with the discussion of advanced care directives. You know, families don't sit down around the Thanksgiving table and say, "Jeez, mom, you know, when you can't make your own decisions, you know, what do you want to do?" You know, they haven't had that conversation. It's very uncomfortable, but we, we see our individuals that come into our program. They are who they are. They come to us with strengths that other people may not see, but since we didn't know them before, we can really hone in on those strengths and help to build those strengths and allow them to become engaged in life again at a level that maybe they haven't been for a long time. So usually within the first 90 days we see a, a gigantic change in the quality of life and the smiles on the faces and the engagement within the center when they come in. They have new friendships, they are, they are engaged at a level in life that they didn't think they could do it again. And it allows us to walk home every night when we walk away, to have that warm, fuzzy feeling in your heart that you did something good. And, and that's why we do the things we do.
Ashton: And I think the important thing to remember too is that Elderhaus PACE was the first in North Carolina. However, there are 11 pace programs now in North Carolina or 11 sites. There's Asheboro. There's Asheville, there's Fayetteville, there's, Durham…
We have folks who live independently with no support. Some folks with no support from family. Uh, we love to have family on board and that's how we do the bulk of our care. But um, who are living independently that most, some folks you'd look at them and go, I don't know how they're doing this, but they're doing it with the support of PACE. They might have memory loss, they might have other issues, but they are living independently in homes they have owned or lived in for 50 or 70 years and they're not having to move out of their home into an assisted living or into a nursing home because they have the support of PACE. They have a day center to come to you. They have medical care 24 hours a day. They can call us and they can talk to a nurse at 2:00 AM and say, listen, I'm having this episode. I don't know what to do and we can let them know, hey, well we're going to come out, try this medication, go to the hospital, call 911, whatever we need to tell them to do. They get socialization, they're not isolated in their homes. They get the care they need to continue to be able to walk or move around their home and we have folks who live in wheelchairs and still live by themselves. You know, we it. It's really a beautiful program in that you get to see individuals who come in and otherwise would be eligible to be in a skilled nursing facility, could go in there at any moment, and they're in our program for six, seven, eight years and still living independently.
Gina: It reminds me of like hospice but …
Ashton: You have a good way of actually I think presenting PACE in that capacity.
Steve: I think, I think when we, when we look at the health plan as a whole, you know, hospice is truly end-of-life. We provide hospice-like services, you know, palliative care toward end of life. We, we know our participants very well. I mean, most of them have been the average length of stay within the a PACE program is someplace around two and a half to three years. We have participants that have been with us 10 years, so we know them inside and out. We know in looking at them whether they're having a good day or bad day. We are able to react to that in a very positive approach and can immediately get them in to see, to see a physician or a nurse practitioner. If you or I go to our doctor, we see him for probably or her for 10 to 15 minutes, you know, we spend a lot of time with the PA, a lot of time with the nurse. Our participants, if they need to see that doctor for an hour, they get an hour with the doctor. I mean they have levels of healthcare that is unprecedented out there in the community. They have the availability 24/7 of whatever services they need. We do a lot of, again, all inclusive. We're in the home sometimes keeping people functional in the home is taking their washer and dryer and putting it on a pedestal so they can continue to do their laundry. The decisions and the, the answers the right answer to keep somebody safe and well in the community, may not be medical, but everything in the fee for service world drives it to a medical decision. You know, sometimes having somebody pet a dog drops their blood pressure, it's not a pill. And so doing all of those things in a holistic approach to end of life, to looking at people as individuals with goals and desires in life.
And how do we meet that? How do we help them meet it? You know, how do we walk the path with them? You know, there are basically three paths that once somebody comes into PACE that, that they can go down. One is longevity. You know, I want everything done. You know, I want to be in the hospital every time I need to go and whatever you need to do to me, you do it, you know, one is, is maintenance, you know, keep me, keep me well. You know, let's maintain me as long as we can. And the other is palliative, you know, keep me comfortable, pain-free, comfortable, do the things you need to do to, to keep me that way. We will walk either of those, any of those paths with the participant. It's, it's their life, we're just there to support.
Gina: Tell me about what's happening this weekend because I think something's happening this weekend.
Ashton: Yes. We are having a PACE open house at our location across from the hospital and we are doing a number of things during that open house. You'll have the ability to come and see our day center, so you will see where our physical therapy and occupational therapy takes place. You'll be able to see where, we encourage exercise every day. So you'll see our wellness center, you'll see our clinic, you'll meet staff members. So we'll also have health screenings. So we'll have balanced screenings with our physical therapists. Our occupational therapists will show some different techniques as well as medical equipment that others might need in the home. Our nutritionist will be on staff to talk about nutrition trends currently happening and we will also have our, a couple of our nurses on staff doing vitals checks, so blood pressure screenings ,and then also our social work team will be there doing some education and training on caregiver stress and behavioral health in the older adult population.
And then we will also have some activities for kids going on outside. Trolley Stop will be there with hot dogs for purchase and we will have um, some kids games, face painting, some other things going on, um, as well outside the center.
Gina: So this is, it's like the whole family can come and just check out this program.
Ashton: Yes. A lot of folks in the community that are caring for their loved ones are what you call that sandwich generation. So they are tasked between caring for children under the age of 18 and their parents. And so this is a great opportunity to get to see that. It's Saturday from 10 to 2 and you can stop by anytime. Like we said, there'll be tours and other educational sessions going on.