March 2007

Grant Results

SUMMARY

The National PACE Association, along with the National Rural Health Association, convened the Rural PACE Summit on September 18–20, 2002, in Roanoke, Va. PACE (Programs of All-inclusive Care for the Elderly) is a service delivery model that integrates medical and social services.

Key Results

  • The 40 invited PACE participants — providers, rural health experts and state and federal policy-makers — identified barriers to PACE development in rural areas and developed an action plan, Setting the PACE for Rural Elder Care: A Framework for Action, with recommendations for expanding the availability of PACE programs in these communities. It is available from the National Rural Health Association Web site.
  • The National PACE Association also developed Setting the PACE for Rural Elder Care: Three Rural PACE Case Studies. See the Bibliography.

Funding
The Robert Wood Johnson Foundation (RWJF) provided $44,415 to partly fund the summit.

 See Grant Detail & Contact Information
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THE PROBLEM

Disabled and elderly residents living in rural communities could benefit from a health care service delivery model that integrates medical and social services. PACE is such a model. Developed in 1971 by On Lok Senior Health Services in San Francisco, PACE delivers social and medical services to low-income, vulnerable elders so that they can remain living in their communities as long as possible.

To enroll in PACE, a person must be 55 years of age or older, need nursing home level of care (based on the state's standards) and reside at home in the program's defined geographic area. PACE providers receive a set monthly payment, or capitation, from Medicare and Medicaid for each enrollee they serve, and are responsible for all of their health care needs, including paying the cost of hospital and nursing home care.

Today, PACE is a success story in many urban communities across the nation: In more than 40 PACE programs, interdisciplinary teams based at PACE Centers provide care there and in enrollees' homes and communities. Yet, PACE has made few inroads in rural America. Partly to blame are the limited number of health care providers serving these areas, long distances between residents and services — and of services from each other — and lower population densities.

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RWJF STRATEGY

RWJF supported the development of the On Lok model of coordinated care for the elderly (ID#s 007846 and 010561) and its spread and replication through a national program, On Lok Approach to Care for the Elderly, which began in 1987. PACE developed from this approach.

Founded in 1994, the National PACE Association, based in Alexandria, Va., advances the work of PACE through policy analysis, advocacy, education, quality assurance, technical assistance and research. From November 1995 through December 1997, RWJF provided the National PACE Association with $159,334 to support the development of a national accreditation program for PACE. See Grant Results on ID# 027957.

Subsequently, from November 2000 to June 2004, RWJF provided the National PACE Association with $747,315 to support it efforts to expand the number of PACE programs and help sustain the association's outreach and technical support activities. See Grant Results on ID# 038642.

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THE PROJECT

The National PACE Association developed a partnership with the National Rural Health Association, a national nonprofit membership organization that provides leadership on rural health issues, to convene the Rural PACE Summit. Approximately 40 PACE providers, rural health experts, and state and federal policy-makers attended the invitation-only conference held September 18–20, 2002, in Roanoke, Va. (See the Appendix for a list of conference attendees.)

RWJF provided partial support for the conference with a grant of $44,415. The John A. Hartford Foundation provided an additional $20,000 and the Office of Rural Health Policy funded commissioned background papers for the summit.

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RESULTS

The project accomplished the following:

  • The National PACE Association published a report, Setting the PACE for Rural Elder Care: A Framework for Action, which synthesizes the findings and recommendations from the summit. According to Project Director Fitzgerald, the report is "a blueprint for action for expanding the availability of PACE in rural areas." Recommendations from the report are outlined below. The complete report is available on the National Rural Health Association Web site.
  • The National PACE Association developed Setting the PACE for Rural Elder Care: Three Rural PACE Case Studies, which examines three rural health care providers considering the development of a PACE program: Geisinger Health System, Danville, Pa.; Midland Hospice, Topeka, Kan.; and Mountain Empire Older Citizens, Big Stone Gap, Va.

Recommendations

The summit report, Setting the PACE for Rural Elder Care: A Framework for Action, outlines the following recommendations:

  • Five core elements of PACE, according to the Centers for Medicare & Medicaid Services (CMS), must be maintained by a rural PACE program. It must:
    • Serve the frail elderly who are 55 or older and eligible for nursing home care.
    • Provide a comprehensive set of preventive, acute and long-term care services.
    • Use an interdisciplinary team of providers to provide and manage care.
    • Pay PACE providers a capitated rate that pools payments from Medicare, Medicaid and private payers.
    • Require PACE providers to assume full financial risk for enrollees by paying for all the health care services enrollees require without any compensation beyond the capitated rate.

However, CMS does offer rural PACE providers a degree of flexibility to tailor their programs to the unique needs and resources of the area through case-by-case review and waivers for demonstration programs.

  • In a rural PACE program, a PACE Center as it is currently operated by urban PACE organizations (in a single, centralized location) may not be feasible. Other approaches could include the use of a mobile center outfitted with the appropriate personnel and equipment that could travel to participants or the creation of several outreach centers that serve a smaller number of participants living within their vicinity.
  • Because all of the necessary interdisciplinary team members are unlikely to reside in a single community in a rural area, advanced telecommunications technology could be used to allow team members to interact with one another and to monitor patients from a distance. Creating a comprehensive interdisciplinary team will likely require establishing partnerships among an array of practitioners and providers.
  • Nontraditional providers can play a critical role in rural areas that lack traditional providers. For example, rural communities can use lay people as health navigators to help enrollees obtain needed care. Family members and neighbors can provide transportation to the centers.
  • To manage their financial risk, rural PACE programs should consider expanding the population they serve by including, for example, younger disabled individuals or those with HIV/AIDS; creating a risk pool across programs by bringing together several PACE programs to share the financial risk of their combined enrollees; or securing reinsurance or stop-loss coverage, which are insurance provisions that would limit the financial risk of PACE programs.
  • Grants from the federal and state governments, as well as local, regional and national philanthropies, will be needed to get rural PACE off the ground.
  • Rural PACE programs will also need access to technical assistance in a variety of areas, ranging from the use of telecommunications technology to understanding federal regulatory requirements.
  • Two models hold promise for rural areas:
    • The rural network model. Under this model, rural health care providers from a variety of organizations and locations partner to provide a full continuum of care. To cut costs, network members could share facilities and equipment. Because network members would come from a wide geographic area, they could reach a large enough population base to support a PACE program.
    • The rural-urban linkage model. Under this model, an existing urban PACE program could expand its reach into nearby rural communities, or a PACE provider could create a new PACE program that connects rural and urban health care providers to serve rural seniors. The program could transport enrollees to urban centers for specialized care or bring care to them via telecommunications technology.

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CONCLUSIONS

In the report Setting the PACE for Rural Elder Care: A Framework for Action the National PACE Association and the National Rural Health Association concluded:

  • PACE can succeed in small towns and in the country just as it has in big cities. Indeed, many of the requisite pieces are in place: a sense of, and commitment to, community; trusting relationships; and a history of cooperation. All that is needed is to begin.

Communications

The National PACE Association disseminated Setting the PACE for Rural Elder Care: A Framework for Action and Setting the PACE for Rural Elder Care: Three Rural PACE Case Studies. The framework for action is available on the National Rural Health Association Web site.

The case study report is available on the National Pace Association Web site.

The reports were also disseminated a professional conferences and through its mailing list. In addition, staff members of the two partner organizations wrote an article, "Rural Policy Development: A National Rural Health Association and PACE Association Collaborative Model," which was published in the peer-reviewed Journal of Rural Health.

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LESSONS LEARNED

  1. It is vital to bring the right group of experts to the table when developing innovative health care service delivery programs. This project merged the expertise of two groups — PACE and the National Rural Health Association — to craft a framework and action plan for a hybrid program, the rural PACE program. In this case, PACE providers who understood the operational requirements of the PACE model were able to work with rural health care providers who had a grasp of the challenges of serving a rural elderly population. (Project Director)
  2. Carefully design any conference intended to explore the feasibility of innovations. The Rural PACE Summit focused on two questions: (1) Can PACE serve rural elders? (2) Is there a need for PACE programs in rural America? Because the conference designers limited and carefully defined the questions, participants were able to hold an effective dialogue. (Project Director)

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AFTER THE GRANT

In October 2003, the National PACE Association and the NATIONAL RURAL HEALTH ASSOCIATION received $582,439 from the federal Office of Rural Health Policy to jointly operate a Rural PACE technical assistance center, which supports 21 rural health providers in the adaptation of the PACE model to their service areas and populations. As a follow-up to the Rural PACE Summit, CMS formed an interdepartmental team to facilitate PACE program development in rural areas.

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GRANT DETAILS & CONTACT INFORMATION

Project

Meeting to Identify Barriers to Rural PACE (Programs of All-Inclusive Care for the Elderly)

Grantee

National PACE Association (Alexandria,  VA)

  • Amount: $ 44,415
    Dates: July 2002 to October 2004
    ID#:  046105

Contact

Peter Fitzgerald
(703) 535-1521
peterf@npaonline.org

Web Site

http://www.npaonline.org

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APPENDICES


Appendix 1

(Current as of the time of the grant; provided by the grantee organization; not verified by RWJF.)

Participants in the Rural PACE Summit

Judy Baskins
Vice President, Geriatric Services
Palmetto Senior Care
Columbia, S.C.

Sandra Bastinelli
Acting Division Director, Special Programs
Centers for Medicare & Medicaid Services
Baltimore, Md.

Denise Bradley
Life Steps Foundation
Oakland, Calif.

Diane Braunstein
National Governors' Association
Washington, D.C.

Charlotte Burrage
Uphams Elder Service Plan
Boston, Mass.

Forrest Calico
Health Resources and Services Administration
Rockville, Md.

Jo Carson
State Representative
Arkansas House of Representatives
Fort Smith, Ark.

Rosemary Castillo
Executive Director
Bienvivir Senior Health Services
El Paso, Texas

Tim Cox
President
Northland Health Care Alliance
Bismark, N.D.

Kim Dannels
Program Manager
National PACE Association
Alexandria, Va.

Karen Davenport
Program Officer
Robert Wood Johnson Foundation
Princeton, N.J.

Sue Davison
Centers for Medicare & Medicaid Services
Baltimore, Md.

John Diaz
Arkansas Division of Aging
Little Rock, Ark.

Sharon Dwyer
Co-Director, Institute of Community Health
School of Public and International Affairs
Virginia Polytechnic Institute and State University
Blacksburg, Va.

Bruce Finke, M.D.
Indian Health Service Eldercare Initiative
Zuni, N.M.

Peter Fitzgerald
Vice President, Strategic Initiatives
National PACE Association
Alexandria, Va.

Robert Greenwood
Vice President, Communications
National PACE Association
Alexandria, Va.

Jan Harris
Centers for Medicare & Medicaid Services
Baltimore, Md.

Catherine Hawes
Professor, Department of Health Policy and Management
School of Rural Public Health
Texas A&M University
College Station, Texas

Matt Hickam
Ombudsman
Kansas State Long-term Care
Topeka, Kan.

Karen Hodgson-Bullock
Chief Executive Officer
Community Health Partnerships, Inc.
Eau Claire, Wis.

John Jones
Executive Director
Deaconess Billings Clinic
Billings, Mont.

Jordan Lewis
National Council of State Legislators
Washington, D.C.

Richard Ludtke, Ph.D.
Professor, Center for Rural Health
University of North Dakota
Grand Forks, N.D.

Alan Morgan
Vice President, Government Affairs
National Rural Health Association
Alexandria, Va.

Tom Morris
Deputy Director
Health Resources and Services Administration
Rockville, Md.

Greg Nycz
Director or Health Policy
Marshfield Clinic
Marshfield, Wis.

Linda Redford
Director, Kansas Geriatric Education Center
University of Kansas Medical Center
Kansas City, Kan.

Gale Remington Smith
PACE/KSPAP Program Manager
Topeka, Kan.

David Reyes
Executive Director
Total Long Term Care
Denver, Colo.

Les Rogers
Administrator
Appalachian Regional Health Care Home Services
Hazard, Ky.

Janet Samen
Centers for Medicare & Medicaid Services
Baltimore, Md.

Kirby Shoaf
CEO
Community Care Organization
Milwaukee, Wis.

Carrie Smith
Centers for Medicare & Medicaid Services
Baltimore, Md.

Peter Szutu
President and Executive Director
Center for Elder Independence
Oakland, Calif.

Elizabeth Tanner
Associate Professor
University of Alabama
Huntsville, Ala.

Chris van Reenen
Senior Vice President
National PACE Association
Alexandria, Va.

Jeanette VanderMeer
Assistant Professor
University of Alabama Capstone College of Nursing
Tuscaloosa, Ala.

Steve Wilhide
President
National Rural Health Association
Alexandria, Va.

Wendy Yallowitz
Program Officer
Robert Wood Johnson Foundation
Princeton, N.J.

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BIBLIOGRAPHY

(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)

Articles

Fitzgerald RP, Morgan A and Morris T. "Rural Policy Development: An NRHA and PACE Association Collaborative Model." Journal of Rural Health, 20(1): 92–96, 2004.

Reports

Hawes C and Rushing M. Program of All-Inclusive Care for the Elderly. College Station, Texas: Texas A&M University, 2002.

Setting the PACE for Rural Elder Care: A Framework for Action. Alexandria, Va.: National PACE Association and National Rural Health Association, 2002. Also appears online.

Setting the PACE for Rural Elder Care: Three Rural PACE Case Studies. Alexandria, Va.: National PACE Association and National Rural Health Association, 2004. Also appears online.

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Report prepared by: Karin Gillespie
Reviewed by: Kelsey Menehan
Reviewed by: Molly McKaughan
Program Officer: Wendy Yallowitz

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