Setting the PACE With a Holistic Approach to Better Care in the Home

The traditional model of care responds to patients who have symptoms and relies on practice guidelines that consider results from randomized clinical trials. The problem is these trials often do not include certain vulnerable populations, like older adults with multiple chronic conditions. So, while the traditional model might meet the needs of some patients, it falls short for those who are medically and socially complex.

The good news is that a more personalized model is gaining momentum: patient-centered care, which focuses on each person’s unique goals of care. The Program of All-Inclusive Care for the Elderly (PACE) embodies this model, helping older adults age at home in their communities through integrated medical and social services. Most of those enrolled in PACE are dually eligible for Medicare and Medicaid, and many have multiple chronic conditions such as diabetes, dementia, heart failure and COPD.

PACE uses a team-based approach to care. This means no one provider directs care for a patient. Instead, a team of different disciplines and specialties works collaboratively among themselves, along with the patient and their family, toward the patient’s goals of care. This team-based, patient-centered approach is far more intensive—and more effective—than the traditional model.

For example, imagine a patient who presents with an irregular heartbeat. In the traditional model of care, their primary care physician (PCP) might send them to a cardiologist. After seeing the patient, the cardiologist sends a written report to the PCP. But with a team-based, patient-centered approach, the PCP talks directly with the cardiologist and the patient. This allows the PCP to ask questions and get a more in-depth understanding of the cardiologist’s recommendations and how they can be integrated into the patient’s total plan of care.

Now imagine the cardiologist recommends that the patient start a new medication. In traditional care, a pharmacist would search for potential drug interactions by looking at the new medication with each of the drugs the patient currently takes. But patient-centered care is about more than avoiding one-to-one drug interactions; it’s about optimizing a patient’s medication routine. This means it considers the cumulative impact of all the patient’s prescriptions, over-the-counter meds, vitamins, supplements and herbals. Patient-centered care also considers how someone’s medication routine fits their lifestyle. All this requires close collaboration between the PCP and an expert clinical pharmacist, like a board-certified geriatric pharmacist.

While this all sounds compelling, organizations need the right tools and expertise to succeed. For instance, I went to the recent National PACE Association Summer Conference, where I attended sessions geared toward medical directors and clinicians new to PACE that explored how to promote better outcomes for participants. The event fostered an intimate exchange of information between newer clinicians and more experienced PACE operators, aiming to help providers get the most out of the PACE approach.

For support on a more regular basis, some programs partner with a third party that provides consulting and other key services. Risk adjustment is a prime example, including training on methodology and clinical documentation excellence. For clinicians, documentation is a vital part of their day to day. Patient charts need to be accurate, specific and comprehensive to optimize care as documentation significantly impacts a program’s revenue. PACE, for example, receives capitated payments from the Centers for Medicare & Medicaid Services (CMS). These payments depend, in part, on patient risk scores, which CMS calculates based on certain diagnoses.

Plus, inaccurate documentation can lead to hefty fines during audits. So again, learning from experts is key. Third-party chart audits and routine assessments further drive results. This helps programs be more effective, optimize their revenue and simplify their operations.

Today, there is a significant need for long-term care to support our aging population and an overwhelming desire to age at home. The most effective support takes a holistic, patient-centered approach. With the growth of PACE and other value-based care organizations, there’s an expanding emphasis on patient-centered care. Fortunately, enrollment into the PACE model is positioned to grow over the next decade so more people will have access to this highly regarded program.