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a Division of Health Services Research and Policy, University of Minnesota School of Public Health, Minneapolis
Correspondence: Robert L. Kane, MD, Division of Health Services Research and Policy, University of Minnesota School of Public Health, D351 Mayo (MMC 197), 420 Delaware Street SE, Minneapolis, MN 55455. E-mail: kanex001{at}umn.edu.
Decision Editor: Laurence G. Branch, PhD
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Abstract |
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Key Words: Managed care • Dual eligibles • Elderly • Medicare • Medicaid
The Program for All-inclusive Care of the Elderly (PACE) stands as a model for integrating care for frail older persons (Branch, Coulam, and Zimmerman 1995
; Eleazer and Fretwell 1999; Eng, Pedulla, Eleazer, McCann, and Fox 1997; Kane 1999). It was designed specifically to serve the dual-eligible population, those eligible for coverage under both Medicare and Medicaid. The frail elderly target population is defined by two criteria. They must be (a) dually eligible for both Medicare and Medicaid and (b) considered to be eligible for admission to a nursing home but living in the community at the time of enrollment. As with all dual-eligible managed-care programs, its intention is to pool the resources of the two funding programs in order to gain better integration and avoid duplications and conflicts from different rules for eligibility and coverage. In addition, the flexibility afforded by a single payment pool allows more creative uses of the money to cover whatever services are deemed necessary.
Developed originally to serve an elderly frail Chinese population in San Francisco, PACE has become a federally certified Medicare managed-care program. It was designed to serve a niche market, persons eligible for both Medicare and Medicaid who were deemed eligible for nursing home care but still lived in the community. As might be expected, this is a very small target group of high-risk persons whose capitation rate is substantial. About two thirds of the money comes from Medicaid, but the Medicare rate is a generous multiple (almost 2.5 times) of the base rate. This pool of resources allowed for the establishment of an integrated approach to care, which featured physicians working on salary and a clinical base in adult day health care. A central part of the model was the active inclusion of all those involved in any aspect of the enrollees' care as part of the core team, with regular team meetings and active information sharing. Innovative efforts were made to avoid the use of either acute or long-term care institutions. Creative means were found to tap all available resources to permit housing support from other means and to integrate care into that housing. Because the medical care is provided by PACE physicians, enrollees must forsake their regular providers in order to join. This provision has proved a deterrent to enrollment.
The evaluation of the original PACE demonstration project encountered logistical difficulties (Branch et al. 1995), but PACE did appear to have achieved its goal of reducing the use of institutions. Hospital days and admissions for PACE clients were lower than those for fee-for-service Medicare beneficiaries in general for the first 18 months of the evaluation, an impressive statistic when one considers the frailty of PACE clients. Likewise, PACE clients had fewer nursing home nights and admissions through the 1st year of the evaluation, but the difference dwindled over time. Perhaps commensurately, PACE clients had more ambulatory visits throughout the 24 months of the evaluation. Much less is known about the clinical outcomes of this care. There were few differences between PACE clients and controls in terms of functional status over time. Nor were there many patterns of differences in terms of self-rated health status, quality of life, or satisfaction (Chatterji, Burstein, Kidder, and White 1998).
The hallmarks of PACE have been an emphasis on interdisciplinary teamwork, a reliance on the day care center as a base of operations, and a commitment to keeping clients out of institutions. PACE employs physicians to provide primary care to its clients and to work as part of the integrated care teams. Persons enrolling in PACE must agree to accept PACE physicians as their primary care providers. The dual requirements of heavy use of day care and limited choice of physician have proven to be obstacles to marketing PACE (Kane, Illston, and Miller 1992).
The Wisconsin Partnership Program (WPP) is a PACE variation that attempts to address aspects of that approach that have made it difficult to market; namely, WPP allows enrollees to remain with their own primary care physician and to make substantially less use of day care. To achieve the same level of benefit from use of an interdisciplinary care team that has been a PACE hallmark, WPP created an interdisciplinary care management team composed of a nurse, social worker, and nurse practitioner. The latter has as a major part of his or her responsibility the task of coordinating closely with the primary care provider in order to bring him or her into the care planning and implementation loop. The level of delegation from primary care provider to nurse practitioner varies with the rapport developed.
Two of the four WPP sites, ElderCare in Madison (Dane County) and Community Care for the Elderly in Milwaukee, offer both PACE and WPP options. As part of the federally mandated evaluation of WPP, we had the opportunity to compare aspects of the care received by PACE and WPP enrollees. This article describes the results of the survey of WPP and PACE enrollees from those two sites in the areas of functioning and satisfaction with the care received.
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The questionnaire was modeled after one used in a prior dual-eligible evaluation (Kane, Weiner, Homyak, and Bershadsky 2001) but modified to emphasize elements the WPP staff felt were especially salient to their approach, namely attention to team care and respect for client autonomy. The survey instruments included demographic information; information regarding use of formal and informal care; satisfaction, including issues of access to services; advance medical directives; general health, functional status (activities of daily living [ADLs] and instrumental ADLs [IADL]); and informal caregiver burden (for family of community respondents). Wherever possible, previously tested measures were used. ADL items were derived from instruments developed by Finch and colleagues (Finch, Kane, and Philp 1995). These questions focused on beneficiaries' ability to engage in basic daily activities (e.g., bathing, dressing, toileting, transferring, feeding, and walking). IADL items focused on the beneficiaries' ability to engage in a range of higher order daily activities from shopping to management of finances.
In addition to questions about ability to perform ADLs and IADLs, questions about unmet need for assistance with functional problems adapted from the work of Allen and Mor 1997 were used. For example, people who reported difficulties using the toilet were asked if they had needed help and did not receive it, if they had been wet or soiled because they did not receive this help, and if they had to wait more than 20 min before receiving help. To get at unmet need with regard to transferring, patients were asked if they had needed additional help getting in or out of a bed or chair and did not receive it and if they had fallen as a result of this lack of assistance. Satisfaction questions addressed receipt of services and the nature of the services they received (e.g., were services provided when needed, did personnel communicate effectively, did patients [or families] participate in decision making). Parallel versions of the satisfaction items were used with enrollees and family respondents. The measure of burden was based on the Caregiver Reaction Assessment instrument developed by Given and colleagues 1992. Questions were asked about the extent to which advance directives were used and any pressures felt to adopt them.
Of the 392 elderly WPP enrollees identified, we were unable to locate 10, 24 had died, 3 had moved out of the area, 19 were living in a nursing home, 13 could not understand English and no proxy was available, another 2 had no proxy, 12 beneficiaries and 5 proxies refused interviews, and one interview was incomplete. Interviews were completed with 303 of 321 eligible enrollees or proxies (392 minus 71) for a response rate of 94%. Of these, 215 were beneficiaries, 82 were family proxies, and 6 were staff proxies. Among the 511 PACE enrollees targeted, 14 could not be located, 2 had moved out of the area, 57 had died, 92 had moved into nursing homes, 1 had no proxy, and 14 beneficiaries and 4 proxies refused interviews. Of the 326 interviews with the 345 persons eligible, 200 were with beneficiaries, 82 were with family proxies, and 44 were with proxies; the response rate was 94%.
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Table 7 displays the reports of caregiver burden among the two groups of families. Here again, the differences were modest. More PACE families felt they owed a great debt to their older relatives. They were less likely to feel they had enough physical strength to provide the care needed and that their health was adequate to the care tasks. However, these differences were not significant after a Bonferroni correction.
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The patterns of service use reflect the differences in program design. One area where the two programs differ substantially is their relationship to physicians. PACE hires physicians who work full time caring for enrolled patients, whereas WPP relies on a wide variety of primary care providers, most of whom care for only a few WPP clients each. However, the WPP program operated by the Milwaukee PACE site, one of the two compared here, has made a deliberate effort to concentrate its primary care load among a limited number of physicians. Limiting the choice of physician has generally been viewed as a marketing problem for PACE. However, the Milwaukee site has been able to do this with both PACE and WPP because it deals largely with a hospital clinic population that has not historically experienced continuity of care.
The findings suggest that coordination of care can be achieved in different ways, but it is probably better achieved if the participating physicians have enough of a stake in the care program to capture their attention and motivate them to alter their practice styles to address the complex needs of dual-eligible patients. The WPP program has taken steps to encourage more active participation by a more constrained panel of primary care doctors.
The two sites studied here face different market conditions. One site draws its clientele from poor people who rely heavily on university clinics, where there is an active turnover of physicians. Hence, these patients have no strong option for maintaining their continuity of care. Changing to a PACE physician is not a large transition. By contrast, the other site works largely with older individuals who have established relationships with local physicians and are less inclined to disrupt them. Not surprisingly, since the time of the study the two sites have gone in different directions. The Milwaukee site has kept both its PACE and WPP options operational, whereas the Madison site has merged all its services into the WPP option, which has proven easier to market. Even the continuing PACE site has changed its approach. For example, not all PACE users use the day care program.
Patient reports of satisfaction are often skewed positively (Hall, Feldstein, Fretwell, and Rowe 1990; Owens and Batchelor 1996; Stump, Dexter, Tierney, and Wolinsky 1995). The responses reported here show more variation. Although the level of satisfaction with care is generally high for both groups, there are several areas with room for improvement. For example, a considerable proportion of respondents from both programs indicated dissatisfaction with the energy needed to get care, the coordination of that care, and communication with the health team. The family members identified problems with pain control, interaction with the team, coordination of care, and their overall rating of the medical care provided. The reports of satisfaction with pain control may well reflect some satisfaction bias among enrollees. Although a considerable number reported fairly active pain, most said they were satisfied with the level of pain control they experienced.
Although the proportion of clients with advance directives in both forms of managed care was considerably higher than average (both around 50%; DeLuca Havens 2000; Gordin and Shade 1999), there was no indication of any coercion to execute an advance directive from either plan. As part of their overall care management planning, representatives of both approaches were encouraged to offer advance directives to clients, but the recommendations were apparently low key.
The findings reported here are best interpreted in the context of a second study that compares the WPP experience to matched controls. That study found few differences (Kane, Homyak, and Bershadsky in press). The prevalence of ADL and IADL dependency was lower for the WPP sample than for the PACE sample, but the extent of unmet needs was generally comparable. Overall, there were few areas of significant difference in beneficiaries' satisfaction. The WPP families were more satisfied than either control group that services were provided when needed and were better coordinated. There were no significant differences in the prevalence of any aspect of care burden. Although managed care seems potentially well suited as a vehicle to implement many of the goals of geriatric care, the overall results to date have been disappointing (Boult, Kane, and Brown 2000; Kane 1998). Although PACE is widely cited as a model of well-integrated care, its effectiveness remains to be established. WPP may be a more marketable version of the PACE principles, but its effectiveness has not yet been demonstrated. It is important to recognize that WPP is still evolving as a program. It is trying to learn from its early experience to adapt its approaches as problems are uncovered.
Practice Concepts
Book Reviews
The Forum
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Acknowledgments |
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Received for publication July 26, 2001. Accepted for publication October 31, 2001.
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This article has been cited by other articles:
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  B. J. Kramer and C. Auer Challenges to Providing End-of-Life Care to Low-Income Elders With Advanced Chronic Disease: Lessons Learned From a Model Program Gerontologist, October 1, 2005; 45(5): 651 - 660. [Abstract] [Full Text] [PDF]
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R. L. Kane, P. Homyak, B. Bershadsky, Y.-S. Lum, and M. S. Siadaty Outcomes of Managed Care of Dually Eligible Older Persons Gerontologist, April 1, 2003; 43(2): 165 - 174. [Abstract] [Full Text] [PDF]
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