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Could This Be the Way to Better Home Care in America?

New legislation would expand the popular PACE home care program, but many would be left out

By Liz Seegert

There's no doubt the pandemic put renewed emphasis on the need for viable, long-term care options to help older people age at home or in their community. One of the best known and effective programs to do it is PACE — the 25-year old federal Program of All inclusive Care for Elderly, an alternative to more traditional home and community based services for people 55 and older.

A physical therapy patient and PACE recipient during treatment. Home care, Next Avenue
A PACE recipient undergoes physical therapy  |  Credit: The National PACE Association

PACE uses a team-based approach, which helps people with long-term care needs stay healthier and out of nursing homes longer.

"We must do more to provide access to supportive services for those wishing to remain at home as they age."

PACE integrates and coordinates health and specialty care for enrollees, including primary care, therapy, prescription drugs, social work and transportation. PACE centers also provide meals, recreation and socialization. The program also offers in-home skilled care, personal care services and supports in the home such as ramps, grab bars and other tools that increase participant safety, according to the National PACE Association.

What PACE Does and Where

It costs less to care for such older adults in the community and the quality of life for them is higher in the community, according to Shawn Bloom, president and CEO of the National PACE Association.

There are currently 272 PACE centers in 30 states, serving about 51,000 participants (the availability is due to federal and state funding and state policies). PACE is so popular that more than 800,000 people are on the waiting list to enroll and its programs may be eligible for some of the $12.7 billion for home and community-based services in the new American Rescue Act law.

"PACE has an important role to play when seniors need the type of care and services traditional provided in a nursing home," said Bloom.

Before COVID-19 put some in-person PACE services on pause, Melanie Stapleton, 76, a PACE enrollee in North Carolina, attended a PACE center three days per week. Various health issues and serious depression after the death of her husband had left her virtually homebound, on a trajectory for nursing home care. 

An older woman and PACE recipient holds a peacock statue. Home care, Next Avenue
Melanie Stapleton says the PACE program "is almost like therapy"  |  Credit: Melanie Simpson

"They came and got me and oh, that was so wonderful," Stapleton said. "And I got better, getting out of the house, and they helped me with physical therapy, which I needed."

She also participated in activities like craft-making with the friends she made at the PACE program. "This is a way of getting out and being with each other, and it's almost like therapy. I love my friends," said Stapleton.

Her PACE center has just started reopening recreational programming and Stapleton looks forward to each visit. "They do so much for me. Stuff that I didn't even know existed," Stapleton said.

What The PACE Plus Act Would Do

Sen. Bob Casey (D-Pa.), chairman of the Senate Special Committee on Aging, recently introduced The PACE Plus Act to help states fund additional PACE programs, especially in rural and underserved urban areas, and expand access to existing ones, offering more services to more people when they most need them.

"We must do more to provide access to supportive services for those wishing to remain at home as they age," Casey said in a statement. "If we have learned anything from the pandemic, it is that people want options of where to receive their care and expanding the PACE program will make it easier for states to offer home-based services to people who have complex medical needs."

His bill comes as Congress debates President Joe Biden's infrastructure proposal, which includes $400 billion for home care-based solutions.

PACE in the Pandemic

Throughout the pandemic, PACE programs have demonstrated the strength of what's known as a person-centered model of care, by keeping enrollees safe at home. The rates of COVID-19 infection and death among PACE enrollees has been just one-third of those for nursing home residents, according to Casey. More than 40% of Americans surveyed in March 2021 said they'd be concerned about a loved one needing long-term care in a nursing home.

PACE is primarily designed for older adults on Medicaid, the federal/state program mostly for low-income older Americans. But if eligible, Medicare beneficiaries can "buy into" the program through monthly premiums. However, that can be very costly, often topping $4,000 per month, which puts PACE out of reach for many middle-class people, according to a recent Milken Institute report.

That begs the obvious question: Where are similar programs for the middle class?

"Most people can't afford to pay out-of-pocket," said Nora Super, senior director at the Center for the Future of Aging at the Milken Institute.

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There's a lot of interest in finding alternative solutions to nursing homes after so many died of COVID-19 there. But, Super said, there has long been a sharp line between Medicaid, which covers long-term care, and Medicare, which covers medical care, and it's a difficult barrier to overcome.

"If you get some of these wraparound services at home [ones that blanket a person to support their needs and improve their well-being], then people won't go to the hospital, they won't go to the emergency department, they won't have readmissions or all of these complications," Super said.

Many Medicare Advantage plans from private insurers (purchased by about 40% of Americans 65 and older instead of traditional Medicare) now cover some non-medical wraparound services — like a certain number of home-delivered meals or an aide for a limited number of hours to help with daily activities like bathing or dressing.

Home Care Help in a Few States

But Super is not optimistic that much action to expand programs like PACE to the middle class will happen on the federal level, given the poor track record of long-term care legislation efforts.

However, there has been some activity in the states.

Washington State's Long Term Services and Supports Trust Act, which goes into effect on January 1, 2022, is the first-in-the-nation public benefit addressing the prohibitive cost of long-term care. The law will institute a payroll tax of 58 cents for every $100 earned by Washington state residents (or $30 per month for someone making $60,000 per year); self-employed individuals or those with private long-term care insurance can opt out. Beneficiaries will be eligible for a lifetime benefit of $36,500 to pay for long-term services and supports if they need help with at least three activities of daily living, and after paying into the fund for at least 10 years. 

And California has put community-based long-term care services and supports for Medicare and MediCal (the state's Medicaid program) recipients into its new Master Plan for Aging.

"The demand will continue increasing because of the aging population, fewer caregivers and now the pandemic."

The Milken report suggests using Washington state's approach as a possible national model and fine tuning it, depending on the state. It also recommends insurers offer long-term care policies that middle-income people could afford, providing some level of home-based coverage.  

The report also includes other ideas to help middle-class older adults age safely at home, including enhancing technology solutions for home-based care and scaling up other promising integrated-care delivery programs.

Although it seems as if we have been having discussions to broaden home-based long-term care for the last 30 years, "there's been a lot of recent demand for solutions," Super said, "The demand will continue increasing because of the aging population, fewer caregivers and now the pandemic — which has made a bad situation worse."

Liz Seegert
Liz Seegert New York-based journalist Liz Seegert has spent more than 30 years reporting and writing about health and general news topics for print, digital and broadcast media. Her primary beats currently include aging, boomers, social determinants of health and health policy. She is topic editor on aging for the Association of Health Care Journalists. Her work has appeared in numerous media outlets, including Consumer Reports, AARP.com, Medical Economics, The Los Angeles Times and The Hartford Courant.  Read More
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