First hospice PACE program opens doors, and more are the on way

Hospice director lists benefits to program

The hospice mission shares many of the goals and features of the mission of the Programs of All-inclusive Care for the Elderly (PACE), and so for hospices with enough resources, initiating a PACE program is a natural fit.

"PACE is about palliative care — trying to help people stay comfortable in the end of their days," says Karren Weichert, president and chief executive officer of Midland Hospice Care of Midland Care Corp. in Topeka, KS. Midland became a PACE provider on Feb. 1, 2007, making it the first hospice to open a PACE program.

"I think PACE fits in with what hospices are doing, and needing to become, to serve a greater population," Weichert says.

PACE also provides hospices with an avenue for growth to maintain a competitive edge, she says.

"I think most hospices today are looking at the competition and their own viability, and even though we're hearing about how hospice is growing, it's growing with some growing pains," Weichert says.

Hospices that need to stay competitive should look at the strategic plan and think as far ahead as 2020, she suggests.

"If you are looking at palliative care at all, then I think that looking at a PACE program would be a good fit," Weichert adds.

"PACE is a new model of care and a culture change," Weichert says. "It's a nursing home without the walls, and the reason this is such an easy transition for a hospice to make is because there are so many similarities between hospices and PACE — even in the regulations."

Hospice care and PACE are similar models, and PACE is a natural outgrowth of hospice care and could have a symbiotic relationship with hospices, says Shawn Bloom, chief executive officer of the National PACE Association in Alexandria, VA.

PACE programs are a model of care that provide all preventive, primary, acute, and long-term care services to people who are ages 55 years and older and who are certified by their state to need nursing home care so they can live as independently as possible.

PACE programs receive Medicare and Medicaid capitation payments to assume full financial risk for enrollees' care. So far, there are 38 PACE programs in 20 states, with another 20 programs expected to be opened in 2007, Bloom says.

"We are looking at the doubling of PACE in the next few years," he adds.

The focus point of PACE services is an adult day center where PACE enrollees receive a multitude of health care and support services from dental care to physical therapy. And this is augmented with home care and common sense approaches to whatever services are needed to keep enrollees out of nursing homes and hospitals, Bloom explains.

Midland Hospice Care has had an adult day center since 1992. It was started to complement hospice services, Weichert says.

"It was a safe place for hospice patients to go during the day, and it gives caregivers a break," Weichert says.

In recent years, as the length of stay among hospice patients declined, interest in adult day centers increased among families of chronically-ill older adults, Weichert notes.

"We'd have people call us to see if family members who had strokes or Alzheimer's disease could come to the day program," she says. "Pretty soon, it became a community program for frail elderly adults in the community, completely separate from hospice, although we still had some hospice patients."

The National Hospice and Palliative Care Organization (NHPCO) contacted Midland Hospice to see if the hospice would be interested in becoming a PACE site, as the National PACE Association was looking for more health care providers and others to open PACE programs, Weichert recalls.

"So in 2002 we began to explore that opportunity and what it might involve," she says.

Weichert visited existing PACE sites, and the hospice decided PACE would be a natural fit with the existing adult day program and the hospice's existing expertise.

The next steps were to complete a lengthy application form, and hospice officials asked the Kansas state legislature for PACE funding, Weichert says.

The PACE program finally opened this year, with an adult day program that can enroll up to 75 people and a day center that can serve 51 people at any given time.

The hospice had existing space in which to open a clinic within the day center, and there were facilities with therapy space and men's and women's shower rooms for assisted bathing, so necessary infrastructure was in place, Weichert says.

"We had an advantage where we didn't have all of the upfront costs some sites might have if they were starting from scratch," Weichert says.

PACE sites have to bear the burden of implementing the program, so some organizations will collaborate with health care systems in their community, or they'll seek grants to pay for start-up costs, she notes.

However, CMS recently announced $7.5 million in competitive grants that are being awarded to 15 rural health care provider organizations for the purpose of developing PACE sites. The organizations that will receive a $500,000 grant to support development of a rural PACE program include the Hospice of Siouxland in Sioux City, IA.

Midland's PACE staffing needs were supplemented with contracts, although the hospice did hire staff to coordinate the PACE data, as well as monitor performance improvement.

"We have contracts with therapists, and we use them when we need to, but it is our hope to have our own physical therapist on staff, and we're searching right now," Weichert says.

Demonstration projects from the 1990s showed that a PACE approach can save states Medicare money. PACE provides a variety of services, including transportation, meals, social interaction, and health care to keep frail and older adults from entering nursing homes or from becoming frequent fliers at hospitals. When these patients need end-of-life services, PACE can contract with hospices to provide hospice care, as well, Bloom says.

"The rule of thumb, according to a government study, is that PACE saves Medicare 40%," Bloom says.

The mean Medicaid payment per PACE enrollee who is Medicaid eligible is about $3,000 per month, and the mean Medicare payment per PACE enrollee who is Medicare eligible is about $2,000 per month, Bloom says.

For enrollees who are dual-eligible, as are enrollees at PACE providers, the monthly capitation payment of roughly $5,000 per patient covers all drugs, hospitalizations, specialty visits, therapy, transportation, meals, day care services, etc., Bloom says.

Some providers are pre-PACE providers who operate solely under Medicaid contracts for long-term care services only, and these sites are expected to become PACE providers in the near future.

Hospices can contract with PACE sites, but when Bloom speaks before national hospice , he outlines the benefits to hospices that decide to become PACE providers. Bloom is next expected to discuss PACE at the 22nd Management and Leadership Conference, sponsored by NHPCO, April 19-21, 2007, in Washington, DC.

"I think hospices that have approached us have generally approached us with an interest in PACE," Bloom says.

Hospices have a lot of competencies that are a good starting point for PACE, so there's a natural fit, he adds.

"We routinely provide end-of-life care to individuals in PACE," Bloom says. "And if you look at the place of death among PACE patients, you will see that our place of death statistics are on par with hospice, in terms of giving people the opportunity to die at home, as opposed to in an institution."

The Centers for Medicare & Medicaid Services memorandum clarifies that PACE organizations can contract with hospices for providing end-of-life care and palliative care to PACE enrollees, Bloom says.

So far, maybe 5 to 10 PACE sites contract with hospices, and the others provide in-house palliative care services, since many of the medical directors are board-certified in palliative care, he adds.

"Most of our folks have comorbidities, and the average enrollee is in the program for 2.5 to three years," Bloom says. "They form very strong relationships with the PACE staff."

In the case of Midland Care Connection's PACE, there will be a natural relationship between the hospice and PACE.

"We have an interagency agreement to provide hospice services to our PACE participants," Weichert says. "PACE patients can't be transferred to the hospice benefit, but we contract with ourselves to provide a hospice team, when necessary, and so that becomes a part of the review we do in PACE, and the hospice team becomes part of the interdisciplinary team."

Need More Information?

  • Patricia Martino, RN, CHPN, AAS, Case Manager/Team Leader, The Community Hospice, Inc., 159 Wolf Road, Albany, NY 12205. Telephone: (518) 285-8124.
  • Karren Weichert, President, Chief Executive Officer, Midland Hospice Care, Midland Care Connection, 200 SW Frazier Circle, Topeka, KS 66606. Telephone: (785) 232-2044. Email: karrenw@midlandhospice.org. Web site: www.midlandhospice.org.