Supporting seniors with PACE

BY VERNA SELLERS, MD, MPH, CMD, AND KATHY WORLEY, MSN, RN, FNP-BC

An integral part of the continuum of healthcare, PACE (Program of All-Inclusive Care for the Elderly) is a national program that empowers participants to maintain their independence and live in their homes despite the challenges of aging. These challenges can include chronic disease, social isolation, depression, cognitive impairment and the need for assistance with the activities of daily living.

PACE provides a skilled interdisciplinary team to oversee medical, physical, emotional and spiritual needs. The PACE team includes geriatricians, nurse practitioners, nurses, dietitians, physical, speech and occupational therapists and social workers. PACE drivers transport participants to and from the center, approved referral providers and medical appointments. The program provides seniors with daily activities, meals and exercise programs, all of which are designed to be mentally, socially and physically stimulating. PACE services also include 24-hour on-call nurse and physician services, prescription medicines, clinic visits, mental health care, durable medical equipment and nutritional services.

PACE providers stay by the participants’ sides through the changes in their health and the aging process. Staff members work with them to help improve their cognitive and learning abilities by providing close medical oversight that allows them to anticipate healthcare changes and needs. By following participants through the aging process, the PACE team adapts functional, comfort and end-of-life care plans as needed.

Care where you need it

PACE services are available in participants’ homes, PACE centers, assisted living facilities and hospitals. In-center care can include socialization activities, clinic visits, therapy sessions, meals, snacks, scheduling of appointments and regular assessments.

PACE services at home include an RN home care coordinator who oversees the home environment for safety, a registered nurse coach who oversees transitions during an illness or stay in a healthcare facility, as well as home visits by social workers, rehabilitation therapists and patient care aides. PACE at home provides durable medical supplies necessary to help maximize functioning and independence. Staff members also train caregivers and family members who want to help their loved ones with the activities of daily living.

Considered a safety net for its participants, PACE has been shown nationally to decrease urgent care visits, hospital admissions and number of days in the hospital.

Who is eligible?

To be eligible for PACE, participants must be 55 or older, reside in the PACE service area, be able to live safely in the community with support from PACE and meet state criteria for nursing-home level care.

PACE is a nonprofit program funded through a unique arrangement with Medicaid and Medicare. If a participant is eligible for Medicaid and Medicare — or Medicaid only — there may be no cost to join the program or to receive services provided by PACE. If a participant is eligible for Medicare only, there is a monthly cost. Participants who do not qualify for Medicare or Medicaid may still join PACE by paying out of pocket for services.

Independent at home

Kathy Worley with her mother, Betty.

Betty, 83, doesn’t spend her days alone at home anymore. Although she suffers from blindness and other physical conditions, she is transported several times a week to PACE (Program of All-Inclusive Care for the Elderly), where she receives medical care and enjoys connecting with other seniors from the community.

Because of her fragile health, Betty would qualify for admission to a skilled care facility. Yet since joining PACE, she has been building her strength with the help of PACE staff, so that she can remain safely in familiar surroundings.

Betty’s daughter and caregiver, Kathy Worley, works as a family nurse practitioner at the Centra PACE clinic in Gretna. She has learned first hand the peace of mind that PACE brings to caregivers and families. Knowing that PACE is there to help her mother has enabled her to reclaim the role of daughter, and their visits are now more enjoyable.

Verna Sellers, MD, MPH, CMD, is medical director of Centra PACE. Kathy Worley, MSN, RN, FNP-BC, is a nurse practitioner with Centra PACE-Gretna.