A PACE-Based Approach to Care Disparities Among Seniors

In the wake of the COVID-19 pandemic, the racial gap in life expectancy hit its highest levels since 1998, with Black Americans living six years less than their white counterparts. This gap can be explained in part due to disparities in senior care. Older Black adults are more likely to rely on Medicaid or Medicare as their only form of health insurance and are more likely to report financial strain associated with caregiving. Beyond payer source, Black adults are more likely to receive care in the emergency room than in a primary care doctor’s office. In addition, Black seniors are more likely to move to nursing homes rather than assisted living situations, and when they moved to assisted living facilities, they were more often in segregated settings with higher levels of acuity.

Hispanic communities similarly face unique obstacles in obtaining broader care and senior care. In a survey of Medicare beneficiaries, Hispanics across various geographic regions are less likely to get necessary care in a timely manner. In addition, Hispanics are less likely to get needed care coordination, and Hispanics in rural areas are more likely to report poor experiences regarding medical communication. When it comes to senior care, fewer than 25% of Hispanics aged 40 or older believe that home health workers, assisted living facilities or nursing homes can tend to their cultural needs.

The Value of PACE

The Program of All-Inclusive Care for the Elderly (PACE) is a senior care program that serves individuals aged 55 and up who are certified as needing nursing home care. PACE provides beneficiaries with all medical needs including provider visits, transportation, medications and homecare in order to avoid preventable hospital visits. This program was started in the 1970s in the Chinatown-North Beach community of San Francisco with the goal of supporting the elderly immigrant population in the region, and has since expanded to 148 programs in 32 states as of September 2022.

PACE has proved to be an effective value-based model for providing care to Medicare and Medicare-Medicaid dual-eligible patients relative to fee-for-service comparison groups. PACE participants have reported better management of care, a reduction in preventable hospitalizations and lower long-term mortality. This reduction in adverse outcomes has been a cost saver for the Medicare program, as exemplified by an analysis by the state of Oklahoma that shows that for every 100 individuals served by PACE, the state saves $1,243,044 per year. In addition, PACE programs mitigate disparities in Black-white senior care, as Black patients enrolled in the system emerge with a lower mortality rate than white patients after one year of enrollment.

Why Data Matters

PACE has provided an opportunity to address disparities while effectively incorporating value-based care into senior care. We suggest a data-centered approach in senior care to enhance
these efforts.

As a first step, PACE organizations should collect targeted data to identify disparities in senior care. In order to adequately address disparities, we must understand the specific context and details that underlie them. This data collection should include beneficiary data related to zip code and race, which are tied closely with the social determinants of health.

Creating standardized formats for this data collection can ensure that care teams can address social needs either before or as they occur. On a population level, this can allow PACE organizations to identify patterns in care needs within certain communities that can inform interventions.

An example of this in action would be the Z-code primer that the PACE-focused analytics platform IntusCare employs to allow a clinician to input or see that a patient is experiencing food insecurity. A standardized data structure is necessary to empirically note and begin to address patterns of disparities.

Furthermore, data should be used to identify and analyze disparity trends in PACE populations. This analysis can begin to uncover not only what is occuring, but also the “why” behind existing disparities.

For example, if white patients in a PACE program are healthier, collected data can form the basis of questions to inform interventions. Are these patients more empowered to speak out with their concerns? Do these patients live near a hospital they can admit themselves to? Are the differences due to the pernicious effects of racism in medical care? Asking these questions in a specific context can provide a road map of what markers of care are most important to focus on in the context of a specific PACE program.

Making a Change

Most importantly, targeted data collection must provide the basis for community-based interventions to address disparities in the PACE program. This could include creating specific programs that address a systematic need within a certain zip code that a PACE operates within.

On a systemic level, more effective data collection can also allow PACE organizations to structure partnerships with social service delivery organizations like CityBlock Health and Unite US that focus on patients with managed care plans. Data may also allow PACE entities to focus on preventing negative outcomes in specific disease areas, such as chronic kidney disease, in which significant disparities and outcomes based on race are known to exist. This would provide them with the means to proactively improve care outcomes in their populations.   

In addition, targeted data collection on disparities in the PACE program can form the basis for Quality Improvement (QI) initiatives within PACE to be compared with “benchmark” QI initiatives that exist in the Medicare program, with the purpose to nudge to improve outcomes.

PACE has served high-cost and high-need populations well. Companies like IntusCare are well suited to provide data and internal resources to further support PACE programs in improving care outcomes and alleviating disparities that exist in senior care. The timing could not be more opportune as the U.S. senior population grows and numerous startups—including Papa, Harmonize, DispatchHealth, AlayaCare and Grayce—are working to help seniors age better in the comfort of their own homes. A structural policy focus on identifying and addressing disparities in resources, care and outcomes in PACE programs would better position us to make deeper inroads in their mission.

A holistic use of data in the senior care space that incorporates information about a patient’s access to food, proximity to pollution and potential medication errors, with tools for best practices to improve outcomes, has the potential to alleviate disparities in life outcomes that are the most harrowing and consequential reminder of inequities in our medical system and community. This is an opportunity to leverage technology to bring justice in our health system that benefits individuals in their golden years.