5 Questions With: Candace Keubel, Executive Director of MassPACE

MassPACE, the Massachusetts chapter of Programs of All-inclusive Care for the Elderly, has taken an innovative approach to serving its clients, mostly patients who are dual eligible for Medicare and Medicaid, during the pandemic. While traditionally center-based, MassPACE shifted to an at-home model, sending caregivers out with tablets for telehealth and also setting up social activities, counseling and more. Some centers were even transformed into temporary infirmaries for COVID-19 patients to reduce hospitalization. HomeCare talked with MassPACE Executive Director Candace Kuebel about some of the lessons and about partnering with homecare organizations.

HomeCare: It sounds like MassPACE has done a great job pivoting in these crazy times. Tell me a little bit about what that looked like.
Candace Kuebel: Yes, we were able to pivot literally overnight and I’ll tell you why. It might have been our finest hour, because the PACE model of care was designed 30 years ago to be extremely person-centered. Many of our patients participate in the development and the practice of their daily care plan, along with an 11-member interdisciplinary team ranging from a geriatrician through transportation coordinator; it’s a pretty mind-blowing model. And it’s center-based. A PACE center can be thought of as an adult day health center, but co-located with a soup-to-nuts medical clinic and rehabilitative therapy gym. It’s like social cafe in the front of the house and it’s the Mayo clinic in the back.

Many of our participants traditionally visited the pace center on a regular basis for their social and medical rehab and nutritional needs. Now, some of our participants live in assisted living and they get their socialization at the assisted living, or they are very active in their supportive housing unit for various reasons. Does that mean that they don’t get the care that is delivered by all of these 11 disciplines? Absolutely not. They get in their homes, right? So that model existed already. While challenging, it was something that was already happening. And those challenges were met with opportunities to rapidly redeploy site-based staff to home-based care, as well as to introduce and deploy to more participants important technology—some of which was already happening, but went on steroids during the pandemic.

HomeCare: What was your biggest challenge?
Kuebel: The biggest challenge, and you’ve heard this many times before, was scrounging up the personal protective equipment (PPE). I know I’m singing to the choir here because the home health industry was at the bottom of the food chain in being able to secure PPE. And it is just mind-blowing to us; how do we deliver care into the home? Without it, we cannot ensure the safety of our workers and of our vulnerable patients… We had to be very creative and get it however we could. And then the testing, you know—it was just an unbelievable phenomenon that in America, we would have this situation. But you know what? This healthcare model employs innovative people and resourceful people, and especially the homecare industry; they are the unsung heroes. These are the angels in the healthcare system, the frontline workers who put themselves out there.

HomeCare: What worked better than you expected?
Kuebel: We were so surprised to find that our participants and our employees were willing to do whatever it took to make this work. You think about health care and you think about the fact that these are people who have multiple chronic conditions. These are nursing facility, clinically eligible individuals starting at age 55, up to 65% of them have a comorbidity with some sort of behavioral health diagnosis. This is the kind of population we’re talking about. And they were in lock step with us…

It’s not just about the medical care though, right? It’s about our activity staff that developed activity kits or coloring kits and paints and they delivered them along with their meals. “Here’s your lunch and here’s something for you to do this afternoon,” they said. “And we’re going to call you in the evening while you’re getting ready to take your medication and make sure that everything is okay.” It was very high touch, and they had the ability to do that and the caregivers really appreciated that and were really willing to work with us… That didn’t require any kind of technology or any big shift or anything like that. It was just thinking through, okay, what will make this person’s day better?

HomeCare: What about on the clinical side? And infection control? You were able to keep infection rates really low.
Kuebel: Let me just talk about that for a minute. It took different plans, developing models where, you know, you don’t want to expose 11 members of the care team to one person who may be infected. They came up with these very complicated algorithms, really, such as having one caregiver be assigned to all of the individuals in one housing unit. And that person would go in with an iPad, something as simple as that and would have eyes on the patient and the interdisciplinary team with Zoom or something like that. … That is how we kept people well in the community and how the team pivoted. … You know, I mean, you know, given the highly contagious nature of the virus, its long incubation period and airborne transmission, that is why you’ve had the fatality rates in congregate settings. And that is why we needed to keep people out of there.

HomeCare: What should home health and HME providers know about working with PACE? Or are there things about the PACE model that they might be able to apply to their business model?
Kuebel: Let me just make a very, very important point, and that is that 11-member disciplinary interdisciplinary team is employed by the pace organization. I think of concentric circles; the participant is in the middle of the circle and then that first outer band is the interdisciplinary team. And then the second band is our contracted providers. We contract with thousands of home health agencies; they are our secret sauce and we can’t do this by ourselves. (In terms of working with HME providers,) the beauty of the capitated model is we aren’t limited; we don’t have to get permission. If our team decides that somebody needs a rollator and they subscribed it, it’s not, this person needs to get authorization so she can maybe have it tomorrow. She is at risk. And so let’s get that over to her this afternoon.