Five-year survival in a Program of All-inclusive Care for Elderly compared with alternative institutional and home- and community-based care.

BACKGROUND: Community-based services are preferred to institutional care for people requiring long-term care (LTC). States are increasing their Medicaid waiver programs, although Program of All-Inclusive Care For Elderly (PACE)-prepaid, community-based comprehensive care-is available in 31 states. Despite emerging alternatives, little is known about their comparative effectiveness. METHODS: For a two-county region of South Carolina, we contrast long-term survival among entrants (n = 2040) to an aged and disabled waiver program, PACE, and nursing homes (NHs), stratifying for risk. Participants were followed for 5 years or until death; those lost to follow-up or surviving less than 5 years as on August 8, 2005 were censored. Analyses included admission descriptive statistics and Kaplan-Meier curves. To address cohort risk imbalance, we employed an established mortality risk index, which showed external validity in waiver, PACE, and NH cohorts (log-rank tests = 105.42, 28.72, and 52.23, respectively, all p < .001; c-statistics = .67, .58, .65, p < .001). RESULTS: Compared with waiver (n = 1,018) and NH (n = 468) admissions, PACE participants (n = 554) were older, more cognitively impaired, and had intermediate activities of daily living dependency. PACE mortality risk (72.6% high-to-intermediate) was greater than in waiver (58.8%), and similar to NH (71.6%). Median NH survival was 2.3 years. Median PACE survival was 4.2 years versus 3.5 in waiver (unstratified, log rank = .394; p = .53), but accounting for risk, PACE's advantage is significant (log rank = 5.941 (1); p = .015). Compared with waiver, higher risk admissions to PACE were most likely to benefit (moderate: PACE median survival = 4.7 years vs waiver 3.4; high risk: 3.0 vs 2.0). CONCLUSION: Long-term outcomes of LTC alternatives warrant greater research and policy attention.

Program of all-inclusive care (PACE): past, present, and future.

From modest beginnings in 1973 to over 60 programs nationwide, the PACE concept has proven the value of integrated, interdisciplinary-based care for frail older adults. The evolution of PACE and its regulatory and reimbursement model have changed over time, but the principals of care have remained unchanged. Nationally PACE programs are dealing with some of the same challenges they had 30 years ago and yet PACE programs continue to expand and provide care to an ever wider distribution of populations. The looming issue of ever-growing health care expenditures represents another opportunity for PACE to demonstrate its value while providing a level of quality beyond what could normally be provided by typical Medicare and Medicaid payments for similar conditions and patient characteristics. The future for PACE includes a number of possibilities including flexibility in financing and reimbursement, design changes to work with community-based physicians, potential eligibility adjustments, and growth of rural PACE. The PACE model has clearly demonstrated that in a debilitated, frail population in whom health care expenses would be expect to be high, a combination of team care, managed health care services, and care coordination can lead to both improved health outcomes and reduced expenses over time.

Providing all-inclusive care for frail elderly veterans: evaluation of three models of care.

Frail elderly veterans aged 55 and older who met state nursing home admission criteria were enrolled in one of three models of all-inclusive long-term care (AIC) at three Veterans Affairs (VA) medical centers (n=386). The models included: VA as sole care provider, VA-community partnership with a Program of All-inclusive Care for the Elderly (PACE), and VA as care manager with care provided by PACE. Healthcare use was monitored for 6 months before and 6 to 36 months after enrollment using VA, DataPACE, and Medicare files. Hospital and outpatient care did not differ before and after AIC enrollment. Only 53% of VA sole-provider patients used adult day health care (ADHC), whereas all other patients used ADHC. Nursing home days increased, but permanent institutionalization was low. Thirty percent of participants died; of those still enrolled in AIC, 92% remained in the community. VA successfully implemented three variations of AIC and was able to keep frail elderly veterans in the community. Further research on providing variations of AIC in general is warranted.