The Program of All-Inclusive Care for the Elderly: An Update after 25 Years of Permanent Provider Status.

PACE is the gold standard for community-based integrated care. Over the 25 years as permanent provider status by Centers for Medicare and Medicaid Services, it has evolved in design and grown in numbers served. We review the evidence base, history, and future direction of PACE.

Complexities of care: Common components of models of care in geriatrics.

As people age, they are more likely to have an increasing number of medical diagnoses and medications, as well as healthcare providers who care for those conditions. Health professionals caring for older adults understand that medical issues are not the sole factors in the phenomenon of this "care complexity." Socioeconomic, cognitive, functional, and organizational factors play a significant role. Care complexity also affects family caregivers, providers, and healthcare systems and therefore society at large. The American Geriatrics Society (AGS) created a work group to review care to identify the most common components of existing healthcare models that address care complexity in older adults. This article, a product of that work group, defines care complexity in older adults, reviews healthcare models and those most common components within them and identifies potential gaps that require attention to reduce the burden of care complexity in older adults.

Impact of COVID-19 Stay-At-Home Restrictions on Falls in One Community of High-Risk Older Adults.

AIM: To examine the relationship between falls among high-risk older adults at one Program of All-Inclusive Care for the Elderly (PACE) and the COVID-19 closure of its Day Health Center (DHC), which provides participants with social and rehabilitative services and contributes to their weekly physical activity. METHODS: Self-reported falls during the 3 months before the DHC's closure ("pre-COVID-19") were compared in number and in character to falls during its closure ("COVID-19"). RESULTS: One thirty five participants were enrolled during the entire 6-month period; 37% (n = 50) fell during this time. These participants experienced fewer falls during COVID-19 (mean = 0.64) than they did pre-COVID-19 (mean=1.24, p = .0003). CONCLUSIONS: In this population of high-risk, community-dwelling older adults, an abrupt reduction in activity levels may have reduced falls. Physical activity has been shown to both increase and protect against falls in older adults. The long-term consequences of a comparably prolonged period of inactivity merit further study.

Aligning geriatric medicine fellowships with the Program of All-Inclusive Care for the Elderly (PACE).

Geriatric medicine fellowship programs provide comprehensive training to one-year clinical fellows and must demonstrate successful progression of competence among fellows by reporting on 23 milestones to the Accreditation Council for Graduate Medical Education (ACGME). The Program of All-inclusive Care for the Elderly (PACE) is a model of care located throughout the United States and can serve as a training venue for fellows. We surveyed 113 fellowship program directors with a response rate of 42% (n = 48). The purpose of the survey was to assess: (1) familiarity and access to PACE and (2) perceived value of PACE to the fellowship program with regard to training and ability to achieve success in the 23 reporting milestones. Milestones involving communication and team management skills were most consistently identified as very valuable with a PACE clinical rotation. We then convened a focus group of four PACE medical directors who developed a fellowship curriculum for use in training fellows at PACE. We discuss the limitations of our design as well as the opportunities to build on the strengths of that model as a training site for fellows.

Age-Related Hearing Loss and the Listening Environment: Communication Challenges in a Group Care Setting for Older Adults.

Ensuring that older adults in long-term care settings can effectively communicate is important. The goal of this study was to characterize key modifiable factors that could affect verbal communication in an adult day care setting, namely prevalence of audiometric hearing loss and the acoustic characteristics in the activity hall. The prevalence of age-related hearing loss among participants (n=51) was 71%, although only 15% of enrollees at the group care setting (n=21 of 140) used amplification. The noise and reverberation characteristics of the activity hall revealed signal-to-noise ratios of -3.1 decibels (dB) and -2.4 dB during morning activity and lunch, respectively, which are poorer than the recommended levels for understanding speech in background noise. Older adults attending adult day services are likely to spend the day in a room with acoustics that are too challenging to understand speech clearly. Opportunities to improve listening environments in group care settings for older adults are discussed.

Physicians' Responsibilities for Deaths Occurring at Home.

Deaths occurring at home are increasing in the United States. Primary care physicians and trainees may not be explicitly taught about management of deaths in the home. Physician responsibilities for expected and unexpected deaths at home are summarized. The medical examiner should be contacted if death was due to natural disease processes but occurred suddenly or when a physician was not treating the decedent. Police and emergency personnel are often called after terminally ill individuals have died at home, which may cause significant family distress and is typically not necessary if the death was expected. Clinicians should counsel patients and families on managing expected deaths without involving emergency personnel. There is also the question of autopsy, which has become less common throughout the country. Although there are no requirements for physicians to ask families whether they want an autopsy if the death occurred at home, unexpected deaths should be referred to the medical examiner for possible forensic or medicolegal autopsy. If the medical examiner declines the case, the family can be offered private-pay autopsy; costs can exceed $3000. Regarding the completion of death certificates, it is appropriate for the physician to write "probable'' or "presumed" for diagnoses when the precise cause of death at home is uncertain. After a person has died, clinicians can still offer significant postmortem guidance and closure to the family.

Hearing Care Intervention for Persons with Dementia: A Pilot Study.

OBJECTIVE: Hearing loss is a commonly unmet need among adults with dementia that may exacerbate common dementia-related behavioral symptoms. Accessing traditional audiology services for hearing loss is a challenge because of high cost and time commitment. To improve accessibility and affordability of hearing treatment for persons with dementia, there is a need for unique service delivery models. The purpose of this study is to test a novel hearing intervention for persons with dementia and family caregivers delivered in outpatient settings. METHODS: The Memory-HEARS pilot study delivered a 2-hour in-person intervention in an outpatient setting. A trained interventionist provided hearing screening, communication strategies, and provision of and instruction using a simple over-the-counter amplification device. Caregivers (N = 20) responded to questionnaires related to depression, neuropsychiatric symptoms, and caregiver burden at baseline and 1-month postintervention. RESULTS: Overall, caregivers believed the intervention was beneficial, and most participants with dementia wore the amplification device daily. For the depression and neuropsychiatric outcome measures, participants with high symptom burden at baseline showed improvement at 1-month postintervention. The intervention had no effect on caregiver burden. Qualitative responses from caregivers described improved engagement for their loved ones, such as laughing more, telling more stories, asking more questions, and having more patience. CONCLUSION: The Memory-HEARS intervention is a low-cost, low-risk, nonpharmacologic approach to addressing hearing loss and behavioral symptoms in patients with dementia. Improved communication has the potential to reduce symptom burden and improve quality of life.

Training and maintenance of a picture-based communication response in older adults with dementia.

We examined whether adults with dementia could learn to emit a picture-based communication response and if this skill would maintain over time. Three women with moderate to severe dementia were taught to exchange a picture card for a highly preferred activity. All participants quickly learned to exchange the picture card and maintained this response without practice.

The impact of complex chronic diseases on care utilization among assisted living residents.

PURPOSE: Many residents of assisted living (AL) have chronic diseases that are difficult to manage, including congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD) and diabetes mellitus (DM). We estimated the amount and intensity of care delivered by the staff for residents with these conditions. METHODS: We performed a secondary data analysis from the Maryland Assisted Living (MDAL) Study (399 residents, 29 facilities). In-person assessments included measures of cognition, function, depression, and general medical health. Diagnosis of CHF, COPD, and DM, as well as current medications was abstracted from AL medical charts. Measures of care utilization were operationalized at the resident level as: 1) minutes per day of direct care (caregiver activity scale [CAS]), 2) subjective staff ratings of care burden, and 3) assigned AL "level of care" (based on state regulatory criteria). RESULTS: In best fit regression models, CHF and DM were not significant predictors of the evaluated care utilization measures; however, COPD was independently associated with increased minutes per day of direct care - 34% of the variance in the caregiver activity scale was explained by degree of functional dependency, cognitive impairment, age, and presence of COPD. Functional dependency, depressive symptoms, and age explained almost a quarter (23%) of the variance of staff care burden rating. For the AL level of care intensity rating, degree of functional dependency, level of cognition, and age were significant correlates, together explaining about 28% of the variance. CONCLUSION: The presence of COPD was a significant predictor of time per day of direct care. However, CHF and DM were not correlates of care utilization measures. Functional and cognitive impairment was associated with measures of care utilization, reiterating the importance of these characteristics in the utilization and intensity of care consumed by AL residents. Further study of this population could reveal other forms and amounts of care utilization.

When doctors and daughters disagree: twenty-two days and two blinks of an eye.

A cornerstone of American medical ethics is the right to say, "Keep your hands off of me," to decline medical treatment. A central problem is how to decide about individuals who have become incapacitated and can no longer request or refuse potentially life-sustaining treatment. An advance directive is a formal attempt to protect people's right to autonomy when they are no longer autonomous. As such, it assumes that previously expressed wishes are precise and immutable, but many families make decisions together, and individuals may negotiate, compromise, and modify their genuine preferences, especially when novel threats arise, and the stakes are high. The current article describes a case in which two daughters overruled a patient's explicit preference to refuse life-sustaining treatment, leading to burdensome illness before death. In the end, the mother seemed to understand her children's needs and seemed willing, at least in retrospect, to have met those needs. After the death of this individual, we continued to talk with the daughters and videotaped an interview in which they shared their perspectives on the case. The daughters consented to be videotaped and to share the video with the medical community (available in online version of article). Their forceful devotion to their mother and their search in retrospect for what could have been done differently has completely changed our understanding of events. We believe that the daughters' behavior is not the indefensible breach of respect for person that it seemed to be. Their mother's true wishes might well have included a desire to help her children during her own dying. Family members' preferences are likely to be important considerations for many people, although the possibility of coercion has to be acknowledged as well. Accommodating this level of decision-making complexity is highly problematic for our understanding of advance directives.

The "continuum of care" for older adults: design and evaluation of an educational series.

Geriatricians work within a continuum of health services designed to meet the diverse care needs of older adults. They must develop expertise in these care models and be able to guide safe and efficient transitions. This article describes a 9-week educational series designed to review the evidence base and practical aspects of implementing key services that span the continuum of care for older adults. The sessions in the series covered geriatric assessment, ambulatory care, acute hospital, house call, hospital-at-home, Program of All-Inclusive Care for the Elderly, assisted living, inpatient consultation, rehabilitation, nursing home, chronic hospital, and palliative care and hospice. To assess the educational effect of these sessions, evaluations were collected at the end of each session, including one "summative evaluation" after the completion of the entire 9-week series. The vast majority (97%) of survey responses evaluating individual sessions were positive (scores of 4 or 5 on a 5-point Likert scale), and 89% of responses on the summative evaluation were in that range. This educational series efficiently provides a sequential "tour" of health services for older adults, allowing learners to appreciate the continuum of geriatric care models and relationships between services. Feedback from attendees suggests that this format increases knowledge of health services along the continuum of care for older adults and does so in an efficient manner for learners at different levels of training.

The spectrum of medical illness and medication use among residents of assisted living facilities in central Maryland.

BACKGROUND: Although increasing numbers of older adults are living in assisted living facilities, there is little information on the types and amount of chronic medical illness and the medications required by such residents. To better inform efforts to optimize care in this setting, we sought to quantify chronic medical illnesses and their treatment. METHODS: Medical diagnoses and treatments were derived from chart reviews and interviews of 198 residents of 22 randomly selected assisted living facilities (AL) in central Maryland. To evaluate the burden of medical illnesses, chronic conditions were categorized and quantified according to general (organ system) diseases, as well as 7 specific long-term care Clinical Practice Guidelines (CPG). Using logistic regression, we calculated the associations between facility-level characteristics and those residents with a) conditions from 3 or more general disease categories and, b) 2 or more CPG conditions. To evaluate medical treatment complexity, we categorized oral and certain non-oral medications, as well medications that typically require additional monitoring. RESULTS: Almost one-half (46%) of AL residents had chronic conditions in 3 or more different general disease categories and one-fourth (25.2%) had 2 or more specific Clinical Practice Guideline (CPG) conditions. Residents with chronic conditions in 3 or more different general disease groups were more likely to live in larger facilities; otherwise, no other facility-level characteristics that we assessed were associated with residents having conditions from 3 or more general disease categories or 2 or more CPG conditions. One-half of all residents were taking medications that typically require additional monitoring and 25% of residents were receiving treatments of respiratory inhalers, eye drops and/or injections. CONCLUSIONS: Many AL residents have multiple medical illnesses of different types and complexity. Given the increasing role of AL providers in the management of such conditions, appropriate adjustments in care provision will be needed for facilities to meet the needs of these residents.

Should programs of all-inclusive care for the elderly use community-based primary care physicians?

The program of All-inclusive Care for the Elderly (PACE) is a community-based, long-term care model designed for older adults that are nursing home eligible. Bound by original design and regulations, these programs have primarily utilized a center-based ("staff") primary care physician model. However, some believe that this might hinder expansion of the PACE model. In response to this concern, three PACE programs have explored the use of "community-based" primary care physicians (CBPCPs). In an attempt to evaluate the impact of this variation in the model, we surveyed the medical director, 2 community-based primary care physicians and 6 non-physician staff members at one of these sites. Responders generally support the use of CBPCPs as a useful and productive alternative way to expand PACE services to a wider audience of eligible patients. Because some staff members perceive that CBPCPs utilize hospital and NH services at a higher rate, continued education of both CBPCPs and staff members regarding the expectations from this relationship is needed.

Care needs of higher-functioning nursing home residents.

OBJECTIVES: To quantify and characterize the chronic conditions of older Americans who live in nursing homes (NHs) but have minimal disability and might be able to live in less restrictive and less expensive settings. DESIGN: Secondary analysis of the 1999 National Nursing Home Survey. PARTICIPANTS: NH staff members familiar with the care of residents who were 65 years or older and had resided in the NH for more than 100 days. MEASUREMENTS: We defined "higher-functioning" residents as those who received help from NH staff in 0-2 activities of daily living. We then classified these higher-functioning residents according to their conditions requiring chronic care: impaired mobility, conditions requiring rehabilitation, mental health disorders, incontinence, severe sensory impairment, and medical conditions (congestive heart failure, chronic obstructive pulmonary disease, diabetes mellitus, Parkinson's disease). RESULTS: One-fifth (19.8%) of the NH residents met the criteria for "higher-functioning" (n=1145). Of these, 64.1% had mental disorders, 40.4% had impaired mobility, 20.6% were incontinent, 18% had conditions requiring rehabilitative therapy, 8.7% had severe sensory impairment, and 43.0% had one or more of the four medical diagnoses. CONCLUSION: Many higher-functioning long-stay nursing home residents have chronic care needs that are similar to those of older adults who live in private residences. Many such persons may be able to live in community settings.

Differences in diabetes management of nursing home patients based on functional and cognitive status.

OBJECTIVES: To describe practice patterns regarding diabetes management among nursing home (NH) physicians and to identify variation in this practice based on patient characteristics. DESIGN: Mailed survey. PARTICIPANTS: Nursing home physicians from the American Medical Directors Association (AMDA) Foundation Long-Term Care Research Network (n = 142), as well as other members of AMDA who were Certified Medical Directors (CMD) (n = 68) and members who were not CMD certified (n = 45). Response rates to the survey were 51%, 33%, and 23%, respectively. MEASUREMENTS: Physician and facility characteristics were queried. Responses to 12 items pertaining to diabetes management and 5 items pertaining to use of specific oral diabetes medications were evaluated in the context of 3 different patient profiles that reflected different combinations of functional and cognitive impairment. Responses were based on the physicians' perception of how they manage diabetes under these specified patient profiles. RESULTS: Responses from members of the Research Network indicated highly significant variability (P < .01) between the 3 patient profiles for all of the 12 management items. Ordering a special diet, monitoring lipid panel, and ordering routine ophthalmology was less likely for the patient profile with both functional and cognitive impairment (P < .01). These differences among the patient profiles for these 3 interventions were present in the responses from all 3 categories of physicians (Research Network, CMD, and non-CMD members of AMDA). There was no statistically significant variability among the 3 patient profiles for any of the 3 physician groups regarding the likelihood of using of any of the 5 classes of oral diabetic medications. Non-CMD physicians were more likely to have less NH experience; otherwise, there were no differences among the 3 physician groups. CONCLUSIONS: Nursing home physicians appear to alter the approach to diabetes management based on the functional and/or cognitive status of the patient. This was particularly true for those physicians who were members of the AMDA Foundation Research Network. These findings have implications for initiatives designed to guide clinical practice as well as efforts by regulatory bodies to evaluate appropriate care. Further research is needed to measure the actual impact of different approaches to diabetes management on relevant outcomes in this population.