Community-Based Integrated Care for Older Adults: A Practical Guide

262 Pages·2022·4.112 MB·English

by  Matthew K. McNabney

Community-Based
Integrated Care
for Older Adults
A Practical Guide
Matthew K. McNabney
Editor
123
Community-Based Integrated Care for Older
Adults
Matthew K. McNabney
Editor
Community-Based Integrated
Care for Older Adults
A Practical Guide
Editor
Matthew K. McNabney
Hopkins ElderPlus
Johns Hopkins University
Baltimore, MD, USA
Associate Editors
Judith Baskins G. Paul Eleazer
Heath Care Consultant, PACE Project Clinical Innovations
Manager, South Carolina Department of Geriatric Research and Education
Health and Human Services Center (GRECC)
Columbia, SC, USA Salt Lake City VA Medical Center
Salt Lake City, UT, USA
ISBN 978-3-031-05136-4 ISBN 978-3-031-05137-1 (eBook)
https://doi.org/10.1007/978-3-031-05137-1
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature
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Preface
Older adults are a heterogenous group. Many people maintain good health and high
functional status well into late life. However, as people age there is an increased
likelihood of medical illnesses as well as functional and cognitive impairment. If
that were not enough challenge for older adults and their families, there are also
social and financial factors that can complicate management and can become over-
whelming for people living in the community. This can lead to additional strain on
the family network and often leads to placement in long-term care facilities, such as
nursing homes and assisted living facilities.
Adequacy of medical care is also an issue for many older adults who live daily
lives in a precarious medical state. Typical primary care practices are not adequately
designed or funded to provide the intensive care coordination and timely interven-
tions needed to avoid decompensation of chronic medical illnesses and avoidable
hospitalizations.
Certainly, nursing homes are sometimes necessary to ensure adequate care and
safety. However, there are many circumstances where a comprehensive and coordi-
nated package of services could help to postpone or eliminate the need for place-
ment in a facility. When targeting older adults who are at the greatest need, the care
requirements and coordination needs can be quite intense and costly. Funding
streams for older adults have largely come from Medicare and Medicaid. These
funding sources have mostly led patients and their caregivers to work with primary
care providers and specialists until they are unable to maintain themselves in the
community and have no choice but to move into a nursing home.
Over the past few decades, there have been a few models of care designed to
address those needs and allow older adults to remain in the community. Many start
as “waiver programs” to allow for a demonstration of benefit and feasibility. Some
programs survive, many do not. An important example of a successful community-
based integrated care model is the Program of All-Inclusive Care for the
Elderly (PACE).
PACE was started as a demonstration program in the 1980s. Multiple studies
have demonstrated its financial impact and benefits to patients and their caregivers.
As a result, PACE achieved “permanent provider” status within the Centers for
v
vi Preface
Medicare and Medicaid (CMS) in 1997. PACE now serves several thousand older
adults in the United States who have been certified as eligible for nursing homes but
can be managed in the community with a large, well-trained, interdisciplinary team.
This book is a first of its kind. It provides a comprehensive overview of
community- based integrated care, with a primary focus on PACE. It is a practical
guide, written by those closely involved with PACE, and is intended to walk the
reader through the many layers that are required to achieve this level of service
coordination. The chapters covering PACE include chapters that review “big pic-
ture” topics such as starting a program, policy considerations, and leadership devel-
opment. There are also individual chapters on the various roles and function of the
interdisciplinary team, which is often considered the “secret sauce” of PACE.
We hope this book is helpful to those who are interested in starting a PACE pro-
gram as well as those who are studying this process to gain expertise in public
health policy and finance.
Baltimore, MD, USA Matthew K. McNabney
Contents
Part I Community-Based Integrated Care
1 The International Perspective on Community-Based
Integrated Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Yunhwan Lee, Hidenori Arai, Ulrike Dapp, and Réjean Hébert
2 The United States Perspective on Community-Based
Integrated Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Cheryl Phillips
Part II The U.S. Prototype: Program of All- Inclusive Care
for the Elderly (PACE)
3 History and Policy Evolution of the PACE Model of Care . . . . . . . . . . 35
Shawn Bloom
4 Evaluating the Effectiveness of PACE . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Sean Hennessy and Bruce Kinosian
Part III The Organization and Management of PACE
5 Leadership in PACE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Ellen Garcia
6 Starting and Growing a PACE Program . . . . . . . . . . . . . . . . . . . . . . . . 81
Joan Kwiatkowski, Emily Drennan, and Victoria Parker
7 The State’s Role in the Implementation of PACE . . . . . . . . . . . . . . . . 105
James Pezzuti and Judith Baskins
8 Medication Management and Part D Coverage in PACE . . . . . . . . . . 125
Catherine Knuth, Richard Mueller, Kathryn Dorward King,
and Ashley Souza
vii
viii Contents
9 Core Components of the Typical PACE Center . . . . . . . . . . . . . . . . . . 139
Kristie Hartig, David Wensel, and Gwen Graddy-Dansby
Part IV The PACE Team and Essential Roles
10 The Interdisciplinary Team and Process in PACE . . . . . . . . . . . . . . . . 157
Becket Lauten and Lori Calkins
11 The Role of Social Work in PACE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169
Heather Hill and Janice Braxton
12 The Role of Recreational Therapy in PACE . . . . . . . . . . . . . . . . . . . . . 175
Susan Disman and Kelsey Ellis
13 The Role of Transportation in PACE . . . . . . . . . . . . . . . . . . . . . . . . . . 183
E. J. Rice and Matthew K. McNabney
14 The Role of Direct Care Providers in PACE . . . . . . . . . . . . . . . . . . . . . 189
April Holmes and Renee Newmuis
15 The Role of Nursing in PACE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195
Mary Austin and Suzanne Fortune
16 The Role of Home Care in PACE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203
Anita Pope
17 The Role of Medical Providers in PACE . . . . . . . . . . . . . . . . . . . . . . . . 211
Peter DeGolia, Gwen Graddy, and Matthew K. McNabney
18 The Role of Medical Director in PACE . . . . . . . . . . . . . . . . . . . . . . . . . 217
Catherine Eng
19 The Role of Rehabilitation in PACE . . . . . . . . . . . . . . . . . . . . . . . . . . . 223
S. Hanlon Newhall, June Nicholas, and Deny Stiassny
20 The Role of Dietician-Nutritionist in PACE . . . . . . . . . . . . . . . . . . . . . 233
Dana Kennedy
Part V Special Aspects of the PACE Model
21 Care Planning in PACE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243
Lisa Jenkins
22 Care Coordination and Transitions of Care in PACE . . . . . . . . . . . . . 253
Sarah Babineau
23 End-of-Life Care in PACE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 261
David Wensel
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265
Contributors
Hidenori Arai National Center for Geriatrics and Gerontology, Obu, Aichi, Japan
Mary Austin Senior Pathways LLC, Phoenixville, PA, USA
Sarah Babineau Providence ElderPlace, Seattle, WA, USA
Judith Baskins Heath Care Consultant, PACE Project Manager, South Carolina
Department of Health and Human Services, Columbia, SC, USA
Shawn Bloom National PACE Association, Alexandria, VA, USA
Janice  Braxton Social Work Department, Piedmont Health Senior Care,
Burlington, NC, USA
Lori Calkins Nursing/Operations, Providence ElderPlace, Seaside, OR, USA
Ulrike Dapp Research Department, Albertinen-Haus Geriatrics Center, University
of Hamburg, Hamburg, Germany
Peter DeGolia McGregor PACE, Cleveland, OH, USA
Susan Disman Providence ElderPlace Washington Providence St. Joseph Health,
Seattle, WA, USA
Emily Drennan PACE Organization of Rhode Island, Providence, RI, USA
Kelsey Ellis Providence ElderPlace Washington Providence St. Joseph Health,
Seattle, WA, USA
Catherine Eng On Lok Senior Health Services, San Francisco, CA, USA
Department of Medicine and Geriatrics, UCSF School of Medicine, San
Francisco, CA, USA
Suzanne  Fortune Quality and Patient Safety, Ascension Living HOPE,
Wichita, KS, USA
ix
x Contributors
Ellen Garcia Providence ElderPlace Oregon, Portland, OR, USA
Gwen Graddy-Dansby PACE Southeast Michigan, Dearborn, MI, USA
Gwen Graddy PACE Southeast Michigan, Detroit, MI, USA
Kristie  Hartig Community Nursing, Midland Care Connection, Inc,
Topeka, KS, USA
Réjean Hébert Department of Health Management, Evaluation and Policy, School
of Public Health, Université de Montréal, Montréal, QC, Canada
Sean  Hennessy Division of Epidemiology, Department of Biostatistics,
Epidemiology and Informatics, University of Pennsylvania Perelman School of
Medicine, Philadelphia, PA, USA
Heather Hill Social Work Department, Providence ElderPlace, Portland, OR, USA
April Holmes Hopkins ElderPlus, Baltimore, MD, USA
Lisa Jenkins Supportive Care Services, Community LIFE, Pittsburgh, PA, USA
Dana Kennedy Community LIFE, Pittsburgh, PA, USA
Kathryn Dorward King Rochester, NY, USA
Bruce Kinosian Department of Medicine, University of Pennsylvania Perelman
School of Medicine, Philadelphia, PA, USA
Catherine Knuth Milliman, Brookfield, WI, USA
Joan Kwiatkowski PACE Organization of Rhode Island, Providence, RI, USA
Becket Lauten Social Work, Providence ElderPlace, Portland, OR, USA
Yunhwan  Lee Department of Preventive Medicine and Public Health, Ajou
University School of Medicine, Suwon, Gyeonggi Province, South Korea
Matthew  K.  McNabney Hopkins ElderPlus, Johns Hopkins University,
Baltimore, MD, USA
Richard Mueller Mequon, WI, USA
S. Hanlon Newhall Hopkins ElderPlus, Baltimore, MD, USA
Renee Newmuis Hopkins ElderPlus, Baltimore, MD, USA
June Nicholas Hopkins ElderPlus, Baltimore, MD, USA
Victoria Parker PACE Organization of Rhode Island, Providence, RI, USA
James Pezzuti Harrisburg, PA, USA
Cheryl Phillips SNP Alliance, Washington, DC, USA