Numerous provider and payer teams are starting to build the infrastructure for an era of accountable care. But some providers already are old hands at coordinating care and bundled payments due to their participation in the Program for All-Inclusive Care for the Elderly (PACE).

The federal program requires providers to manage the medical, social and rehabilitative services for “dual-eligible” patients who qualify for both Medicare and Medicaid benefits, and meet the standards for nursing home care. The goal of the program is to keep those patients living at home and out of institutional care settings. An estimated 9 million U.S. citizens are dual-eligible, and the numbers are swelling as the population ages.

The PACE program is a logistical and technological challenge for organizations that have to coordinate the efforts of numerous caregivers driving across a wide geographic area and delivering complex services to a very vulnerable population.

Summit Eldercare, Worcester, Mass., is the largest PACE provider in New England and focuses solely on a senior population. Since 1995 it has operated under the stringent clinical and financial requirements of the PACE program. It currently oversees care for around 850 patients in central Massachusetts. “We already incorporate all of the features that you would see in a health home, a medical home or in an accountable care organization,” says Karen Longo, executive director of Summit Eldercare. “The models are newer models are being developed to make the PACE model more scalable to larger populations—PACE programs are by regulation limited to dual-eligible patients who otherwise would be in a nursing home.” PACE programs operate under a bundled payments model and receive monthly capitated payments from both Medicare and Medicaid.

In a nutshell, PACE providers are taking on the tough cases—low income, frail, elderly patients who have limited personal resources to manage their health. To keep these patients out of nursing homes is a constant struggle for caregivers and the host of related health professionals—who run the gamut from food and transportation services to mental health providers.

While the PACE environment is one that cries out for electronic records, Longo says Summit Eldercare had problems finding an EHR that had the capabilities to coordinate care to the level required. “We needed a lot of custom tools that help us deal with all of the needs of the other disciplines that are part of the PACE model of care—activities coordinators, speech therapists, nutritionists, physical therapists, and a host of others. There are all kinds of lines of business, and most solutions are built for subsets.” Summit Eldercare chose an EHR from NextGen because it had the clinical features required for medical staff and was customizable to enable input from those other business lines, Longo says.

Everything relies on the care plan, says David Wilner, M.D. It is an all-day, everyday plan that has to be flexible enough to provide a customized treatment plan built on the unique needs of each patient. “It’s not so much a documentation tool as it is a communication tool for us, since not only do we need to coordinate the medical care but also coordinate the interactions we’re having with family members and other people in the patient’s life,” says Wilner, Summit’s medical director.

The Summit staff, including Wilner and Longo, worked with the Next Gen staff to develop a customized care plan tool. It was built on a different definition of “care plan” than most clinicians use. “Most caregivers when they think of a care plan think of a plan specific to their discipline, or a multi-disciplinary plan,” Longo says. “We work with an interdisciplinary plan—a good example would be a patient with a high fall risk. That’s something that needs to be managed in an interdisciplinary fashion—rehabilitation would do assessments and initiate treatment, home care would do a home safety assessment, nursing would do an education of the family members and patient around reducing fall risks. But rehabilitation staff, for example, would have an additional care plan, for example, which would have a goal to ambulate X-many feet, or increase range of motion to reach the grab bar. So with this tool we’re doing the interdisciplinary care plan, and each discipline is doing its own granular care plan.”

While technology puts everything in one place, it’s up to the caregivers to work together to come up with an actionable plan based on the data, Wilner says. “You could have the computer search fields and merge everything into one document, but it wouldn’t meet the needs of our organization. It’s actually a group of professionals who sit down together and talk about their concerns for each patient. It’s based on professional judgment and observations from each facet of the interdisciplinary team. The fact that a family caregiver is stressed out, for example, influences how we as a team go forward with treating that individual.”

In addition, there are quality, health management and disease management tools built into the EHR that enable caregivers to set thresholds and timetables for tests and assessments. Summit Eldercare also continues to fold more information into the EHR by hunting down information that still exists outside the electronic form. “If someone tells us they’re tracking info using an Excel sheet or documents in a binder, most times we can figure out a way to get that information into the electronic record,” Longo says.

The National PACE Association is currently holding its annual conference in New Orleans. For more information about the program, click here.


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