Community-Based Programs and Policies

Contributions to Social Policy Development in Health Care and Health Care-Related Services

Howard A. Palley

• Publisher: Routledge
• Year: 2014
• ISBN:
  9781317993209
• Edition: 1
• Topic: Medizin
• Subtopic: Gesundheitsversorgung

This collection is focused on the provision of community-based programs and activities in health and related long-term care services that have contributed, or may in the future contribute, to social policy development.

Several of the articles in this collection deal with community-based health and long-term care program and policy initiatives that have been facilitated through federal programs such as Medicare, Medicaid and the Older Americans Act. The implementation of some of these community-based programs have significantly influenced social policy thinking regarding the beneficial effects of integrating medical and social aspects of health and long-term care services, as well as the health care team approach to the delivery of health and long-term care services. Another dimension addressed is the impact of interest groups, such as family caregivers, in advancing social policy that supports the efforts of community-based family care givers in providing services to patients in need.

The underlying theme is how such local community programs have contributed in a variety of ways to the development of social policies at the community level that in many ways focus on the integration of health and related long-term care services and a health care team approach to the provision of such services.

The book will be of interest to community development courses in Schools of Social Work and other health professions such as Nursing and Public Health. It will also be of interest to health policy programs in public administration and other social sciences.

This book was published as a special issue of Social Work in Public Health.

Introduction

Howard A. Palley

This collection is focused on community-based programs and activities that have or may in the future contribute to social policy development.

Three of our articles deal with community-based long-term care programs and policies that have been facilitated by federal financing through programs such as, Medicare, Medicaid and the Older Americans Act. In an initial article by Marty Lynch, Mauro Hernandez and Carroll Estes, the authors describe how the Program for All-Inclusive Care for the Elderly (PACE) has significantly influenced social policy thinking regarding the integration of the medical and social aspects of long-term care services. They also view PACE as having provided an influential model for breaking down the vertical silos that often have affected medical and long-term care policies and programs. A companion article by L. Gail Dobell and Robert J. Newcomer examine the various research and demonstration programs sponsored by the U.S. Centers for Medicare and Medicaid Services and discuss several programs delivered in local communities such as Disease Management and PACE and the contributions of such programs to case integration and social policy development. Their article especially emphasizes the collaborative efforts of health and social services professionals that occur within the PACE program. A third article by Philip A. Rozario and Elizabeth Palley addresses long-term care policy by examining programs funded by the U.S. Administration on Aging, as well as Medicaid Waiver Programs, that support family caregiving efforts. In so doing, the authors also focus on the role of family caregiver organizations in influencing national policy to support the efforts of family caregivers in providing support for in-home and community-based resources.

Two articles in this volume focus on the increased emphasis on community-based care in the Canadian health care delivery system. An article by Pierre-Gerlier Forest and Howard A. Palley examines Canada’s policy of fiscal federalism and its interplay with provincial efforts regarding regionalization and community-based health care initiatives in various Canadian provinces. The goal of such policies generally is to provide more cost-effective programs as well as a higher quality of health care in Canada’s provincial health care systems. In their article, Forest and Palley deal, in part, with the experience of Quebec’s Centres Locaux des Services Communitaires (CLSCs)–integrated local health and social service programs. This paper is followed by an article by Benoît Gaumer and Marie-Josée Fleury examining the history, politics and operation of CLSCs. The CLSCs provide an excellent example of a network of community-based programs integrating health and social services and often providing a team approach to the delivery of community-based health and health-related services. Under a recent Quebec reform, general hospitals, CLSCs and long-term care centers have now been merged into a new organizational form known as a Centre de Santé et des Services Sociaux (CSSS). In part, this new reform seeks greater vertical integration of local health and social services.

Next, Cheryl A. Hyde presents an excellent case study of the Womancare Health Center and the challenges it has faced in seeking to provide women’s health services in an atmosphere of intimidation and harassment of its providers and patients. Hyde describes its strategy of expanding health services for women at the community-level as a means of developing community support in spite of ideologically-based anti-abortion and anti-contraception mobilization resulting in legislative constraint and community-based assaults on its ability to deliver needed health care services. Finally, another perspective on advisory committee involvement, that included the participation of consumer and provider groups, in the development of Managed Care Organizations in Medicaid programs in Connecticut is provided by Colleen M. Grogan and Michael K. Gusmano. They provide an excellent evaluation of the effectiveness of advisory committee participation and the need for more open public forum discussion by such advisory groups.

PACE: Has It Changed the Chronic Care Paradigm?

Marty Lynch

Mauro Hernandez

Carroll Estes

Introduction

The Program of All-inclusive Care for the Elderly (PACE) is an excellent example of an innovation developed by a local community that has had significant national policy implications. PACE was first developed by On Lok, a San Francisco elder-serving agency in Chinatown which had introduced adult day health care and wished to create a more comprehensive service to deal with the lack of skilled nursing beds appropriate to the local community (Bodenheimer, 1999). Since that time, PACE has become a Medicare benefit and parts of the model have been adopted by many state Medicaid agencies and other types of organizations interested in chronic care service delivery. To date, PACE replications have been sponsored by other non-profit organizations many of them, like On Lok, relatively small community-based groups. We will describe PACE and selected program-related findings reported in the literature, as well as discuss policy implications in a number of key chronic care areas. In addition, we include a case study describing the development of the Center for Elders Independence (CEI), a PACE site developed by a free-standing non-profit organization in Oakland California, and its impact on the local community.

Methods

The authors completed a review of PACE relevant literature and conducted interviews with several key informants to identify important issues related to policy implications of the PACE program. Articles and reports were identified following title and keyword internet searches of databases such as PubMed and Social Science Citation Index, government websites, such as the Centers for Medicare and Medicaid Services, and the National PACE Association’s website (NPA, 2004). Since the paper is not intended to be a comprehensive review of the PACE literature, the authors selected a number of articles and reports that describe important policy, relevant findings, and program characteristics for integrating health and social services for the elderly. The case study on a local PACE program was developed based on an interview with Peter Szutu, CEO of the Center for Elders Independence, and one of the authors who is a founding Board member of CEI.

What we know about Pace

The Program of All-inclusive Care for the Elderly (PACE) has approximately twenty years of experience fully integrating medical and home and community-based care in a small managed care model for elders with severe chronic conditions (Eng, Pedulla, Eleazer, McCann, & Fox, 1997). Prepaid financing maximizes the flexibility needed to redesign what is otherwise a fragmented and poorly coordinated service delivery system, while risk adjustment mechanisms respond to actual costs of care for target populations (Master & Eng, 2001). Historically, PACE sites received much of their initial development capital from large national foundations. More recently developed programs have emerged from within existing hospital, health care, or long-term care systems that have the necessary resources to support start up costs (Gross, Temkin-Greener, Kunitz, & Mukamel, 2004).

Participant and Program Characteristics

All PACE participants must meet nursing home admission requirements in their state and thus have significant functional Activity of Daily Living (ADL) problems as well as several chronic disease problems. Participants must be at least 55 years old and are generally dually eligible for Medicaid and Medicare. The typical PACE participant is an 80-year old woman who is dependent in three activities of daily living (ADL) and has 8 medical diagnoses. About half of PACE participants have been diagnosed with dementia and most (95%) are Medicaid eligible (Gross et al., 2004; National PACE Association). Once enrolled, participants receive intensive care coordination provided by a multi-disciplinary team that includes the PACE primary care physician, social worker, physical, speech, and occupational therapists, as well as nursing, activity and transportation staff (Shannon & Van Reenen, 1998; Zimmerman, Pemberton, & Thomas, 1998). Most PACE members attend an adult day health center co-located with a primary care clinic and receive the majority of their medical and community-based services in that setting. Depending on individual needs and preferences, additional in-home services may include skilled nursing, personal care, and other household tasks (Gross et al., 2004).

PACE programs typically contract with outside entities for hospital and medical specialty services but retain control of utilization of these services through primary care physician management. Medical providers may have special training in geriatric care or may be internists. PACE programs use information systems, which allow them to gather extensive utilization data on the full range of services provided, manage their costs, and compare themselves to other PACE programs. Some PACE programs are experimenting with electronic medical records (Szutsu, 2001).

Payment incentives in the PACE program support coordination of care and substitution of primary and basic home and community care for high cost acute and institutional care. PACE programs are required to provide basic Medicare and Medicaid services but may also choose to use other less typical interventions (Eng et al., 1997). One PACE program takes its members on fishing trips and has a small drama group, which performs at local events (Szutsu, 2001). PACE programs often are able to avoid or shorten hospital stays by substituting intensive services from the rest of the team in place of hospital care (Eng et al., 1997).

To survive financially PACE programs must manage utilization across a range of hospital, long term care, and specialty services. Although combined capitation payments from Medicare and Medicaid are relatively large, care requirements are also heavy. As noted above, PACE programs have great flexibility in funding educational or preventive activities. They are able to make decisions based on the individual patient’s care plan and overall budget constraints. Given the broad range of medical and long term care risk accepted by PACE programs, they manage greater numbers of dollars per member than most managed care programs and have additional flexibility to fund preventive or community-based interventions (Eng et al., 1997).

PACE programs make efforts to involve their members and family members in the care planning and coordination process. Some PACE programs continue to use family members as caregivers for enrollees. Both physical and cognitive disabilities are significant in PACE programs and may make participant empowerment a challenge (Branch, Coulam, & Zimmerman, 1995).

Selected Outcomes

Reported positive outcomes include, “steady census growth, good consumer satisfaction, reduction in use of institutional care, controlled utilization of medical services, and cost savings to public and private payers of care, including Medicare and Medicaid.” (Eng et al., 1997). Although all PACE members require a skilled nursing facility level of care, PACE programs have been able to provide hospital days per thousand at the level of the general Medicare population, as well as lower short term hospital utilization (Wieland et al., 2000). Looking at the impact of PACE on health service utilization and other outcome measures, one study finds that PACE enrollees, compared with people who decline to enroll, have: lower rates of nursing home utilization and in-patient hospitalization, higher utilization of ambulatory services, better health status and quality of life, and less physical function deterioration. PACE participation was also found to be associated with lower mortality rates (Chatterji, Burstein, Kidder, & White, 1998). In a sample of older participants from eight PACE sites, black patients, who were younger and more disabled, had lower mortality rates than white patients. This survival advantage for black patients emerged after being enrolled in PACE for one year and may be due to improved access to care compared to white patients who may have had better access prior to enrollment (Tan, Lui, Eng, Jha, & Covinsky, 2003). Compared to the general population of older decedents, PACE participants are twice as likely to die at home and half as likely to die in a hospital (Temkin-Greener & Mukamel, 2002).

Nevertheless, questions remain about effectiveness. At times PACE programs are accused of creaming or enrolling less disabled and less costly members, which may mean excluding elders with psychiatric or substance abuse problems (Branch et al., 1995; Holtzman, Chen, & Kane, 1998). Implementation of the PACE model and program characteristics are believed to be uneven as evidenced by reported variation in service utilization, changing disability rates, hospitalization rates and risks among sites (Branch et al., 1995; Mukamel, Temkin-Greener, & Clark, 1998; Wieland et al., 2000). Other reported differences by PACE site have included end of life service utilization (Mukamel, Bajorska, & Temkin-Greener, 2002), care quality (Pacala, Kane, Atherly, & Smith, 2000), and place of death (Temkin-Greener & Mukamel, 2002).

PACE programs have successfully integrated medical and chronic care for those who choose to enroll and most PACE programs have successfully managed a very complex package of care within their budgets (Eng et al., 1997). PACE has become a recognized Medicare benefit in the Balanced Budget Act of 1997 and continues to grow, albeit at a slower rate than anticipated (Gross et al., 2004; Irvin, Massey, & Dorsey, 1997). PACE is also subject to state to state variations based on individual states’ willingness to process PACE applications or negotiate the Medicaid portion of the capitation payment, given concerns about the high cost of providing the benefit. Despite these issues, PACE continues to be one of the few successful models for integrating the full range of medical and chronic care services across both the Medicare and Medicaid programs.

Why are there only 10,000 Pace Participants and 32 Sites?

Slow growth, only 10,000 to 15,000 members nationwide and 32 fully capitated sites as of April, 2005, has limited the impact and significance of the PACE program (Branch et al., 1995; Kane, Illston, & Miller, 1992). PACE programs have only grown at a rate of one to four per year since the federal cap was expanded in 1997 from 16 to 40 programs upon enactment of the Balanced Budget Act, which allowed an annual increase of 20 more programs thereafter (Gross et al., 2004). There has been a limited amount of research on barriers to expansion of PACE. Gross and colleagues (2004) identified a number of barriers to PACE program growth based on 27 site visits and numerous interviews with PACE program management and staff. Interviews with PACE program administrators and staff revealed 16 barriers to participant enrollment growth, which were then ranked using scores from a follow-up survey. Although the importance of the identified barriers varied considerably by program administrator, the top five ranked barriers had to do with: (1) competition for potential disabled members from other state funded home and community-based service (HCBS) programs, (2) competition from operating in a service-rich health care environment where potential members can get their home and community service needs met elsewhere, (3) client unwillingness to give up their primary care physician, (4) out-of-pocket costs for non-Medicaid enrollment, and (5) a lack of understanding about services and eligibility among gatekeepers (Gross et al., 2004). At the federal level, they also reported the inability of potential PACE providers to predict future revenues because of new risk-adjusted Medicare payment provisions that were not made public until 2003. State efforts have also varied considerably given the substantial political will and resources needed to enable PACE program growth by making any necessary legislative or regulatory changes required to contract with additional PACE sites and developing necessary systems for information management, payment, oversight and quality assurance of PACE.

Rural location may also present a barrier for growth. To date, no PACE programs have emerged in rural areas, which tend to have a higher proportion of older residents (Fitzgerald, Morgan, & Morris, 2004). Gross and colleagues (2004) discuss how the program’s reliance on day center attendance may be impractical in areas with lower population density and transportation barriers are more challenging in bringing members to service locations and getting home care workers to members’ homes. The authors report that states with PACE programs average about five times as many persons per square mile as those that do not. As a result, the National PACE Association and the National Rural Health Association received federal funding to explore the modification and development of PACE in rural areas (HRSA, 2004).

In addition to reviewing available literature, we interviewed a number of key informants to provide additional insights on the issue of slow PACE growth. Informants included program administrators, researchers, and regulators familiar with PACE and other home and community-based service models. There were a number of similarities in the issues we identified but also a number of differences. The key question is: “If PACE has indeed inspired many efforts to successfully integrate acute and long...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• List of contributors
• 1. Introduction
• 2. PACE: Has It Changed the Chronic Care Paradigm?
• 3. Integrated Care: Incentives, Approaches, and Future Considerations
• 4. When the Private Sphere Goes Public: Exploring the Issues Facing Family Caregiver Organizations in the Development of Long-Term Care Policies
• 5. Examining Fiscal Federalism, Regionalization and Community-Based Initiatives in Canada’s Health Care Delivery System
• 6. CLSCs in Quebec: Thirty Years of Community Action
• 7. Feminist Health Care in a Hostile Environment: A Case Study of the Womancare Health Center
• 8. The Voice of Advocates in Health Care Policymaking for the Poor
• Index