06/15/11

BY RICHARD O. SCHAMP, MD, CMD

Mrs. Bloomer, 78, is in the hospital 2 days after her hip-fracture repair. Fully attentive, she listens as her doctor – let’s call him Dr. Dan – tells her of the plan to transfer her to a skilled nursing facility for her rehabilitation.

"Don’t worry," Dr. Dan says. "You’ll be able to visit your friends at the center as soon as you’re ready to return home. And I’ll be visiting you at the nursing home." The "center," she happily knows, is the PACE day health center she had been attending regularly before her fracture, PACE standing for Program of All-Inclusive Care for the Elderly.

She reports to Dr. Dan that the PACE social worker and the PACE physical therapist have already stopped in to see her and help with coordination of care during the transfer to the nursing facility.

Continuing his morning hospital rounds, Dr. Dan steps down the hall to see Mr. Baskins, 84. He was admitted for yet another stroke and now faces the need for total care in the short time Dr. Dan and others believe he has left. He has advanced dementia but can eat and walk with assistance. His wife, frail herself, now cannot care for him alone.

She is waiting for Dr. Dan and tearfully describes how her husband is a dignified man and would not want to live in a nursing home in his final days. She expresses gratitude that the PACE interdisciplinary team (IDT) has a plan of care that includes palliative care so Mr. Baskins can return home. His advance directives were clear, and the IDT has already consulted with the PACE’s hospice agency.

That’s the way a typical day in the life of a PACE medical director might begin. From there, Dr. Dan would head to the nearby PACE center just in time for the morning IDT meeting. The center contains an adult day center, a full primary care clinic, physical and occupational therapy space and equipment, and offices for social work and administration. The center is the focal point for the PACE model of care and is the home of the interdisciplinary team. Most PACE participants – people served by a PACE aren’t called "patients" or "residents" – attend the center two to three times a week, according to each person’s plan of care.

Morning Meeting

The IDT meeting includes nurses, a physical therapist, an occupational therapist, the home-care coordinator, a dietician, a recreational therapist, a social worker, the transportation director, a nurse’s aide, the center’s director, and perhaps a chaplain, a pharmacist, the center’s nurse practitioner (NP) or a physician’s assistant. Dr. Dan or another physician always attends.

Today, the intake staff introduces two potential enrollees and schedules team members for comprehensive assessments of the two when they visit the center. These new participants will bring the census to 150, typical for a PACE center.

The local market is larger than that number reflects, however, with Medicare granting PACE eligibility to anybody who is 55 years or older and certified as needing nursing home–level care, as long as they live within the defined service area of one of the 76 PACE programs now operating in 33 states.

At the mention of the census, Dr. Dan marvels at the slow growth. After all, the PACE model embodies key features touted by health care reform advocates: integrated and accountable care, emphasis on prevention and primary care, and care centered on patients and their caregivers. The logic of the PACE model is to provide more care in people’s homes and community settings to prevent more expensive and undesired institutional care. He wonders if PACE is the best-kept secret in health care.

All Present or Accounted For

Next, the on-call nurse reports several overnight calls from participants, and the team decides on who needs to be further assessed for new goals and interventions needed because of acute health changes indicated by the calls. The meeting facilitator notes who is responsible and when to report back to the team.

For example, one participant awoke with dizziness and her caregiver son called 911. Dr. Dan and a social worker are assigned to call or go to the emergency room after the meeting. Depending on what he finds, he and the social worker may assure the participant, her family, and the ER staff that the participant can be managed appropriately at home, with PACE support. The social worker plans to re-educate the family on avoiding unnecessary hospital admissions and ER runs.

The agenda flows on, with team members reporting social problems, incidents, infections, falls, and other changes of conditions that may need follow-up. The notes are recorded and will be distributed to all staff after the meeting. Everyone in the IDT takes seriously the mission to keep the PACE participants living safely in their community.

The meeting concludes with reports on all the outside appointments scheduled for today so the PACE staff can anticipate transportation, communication, and educational needs of the participants and their caregivers.

Dr. Dan and the others note who will need to be seenby a primary care provider in the center today. His acute-care visits will be sandwiched between follow-up visits and scheduled assessments, each assessment and its documentation taking up to an hour and a half.

Out on the Town

The meeting ends. Dr. Dan and the social worker go on their emergency room sojourn, which goes as expected. The work-up was unremarkable, and the PACE team will get the woman home today once her dizziness abates and will follow up closely. A nurse or aide will visit the home later today to ensure she has an evening meal and is taking her medicine, and that her son is aware of her care needs.

When Dr. Dan returns, the PACE clinic is buzzing with participants visiting the NP and other nurses. Dr. Dan dives in, and he and the NP move quickly through the appointments and walk-ins, including a heart failure patient who needs parenteral diuretics and another participant with pneumonia who gets antibiotic injections and will spend the night in a contracted nursing home bed for closer observation. These acute visits are worked in between the routine assessments. The PACE routine calls for a full interdisciplinary assessment of every participant at least every 6 months or when a significant change of condition occurs.

The clinic is busiest between 10 a.m. and 2 p.m., with an average of about 15 participants seeing either Dr. Dan or the NP for primary care each day. Dr. Dan will interact with another 15-20 participants by way of messages, phone calls, and team interactions. Just walking through the day-care area of the center and therapy areas allows informal observation of who is doing well or not. He will often interact with participants and make a note of these observations in the medical record. Dr. Dan and other team members will also make house calls as needed. The rest of the afternoon includes a brief stand-down meeting with health center staff to make sure they closed the loops on issues that came up in the morning meeting and also to touch base about any unstable or at-risk participants.

The IDT is responsible for care in all settings, including the center, participants’ homes, nursing homes, and the hospital. They will follow the 10% of participants who will require long-term nursing home care.

It’s a Long, Rewarding Day

After his documentation is complete for the day, Dr. Dan has a couple of hours to work on some administrative duties. As medical director, he is responsible for clinical outcomes as well as for the facility’s "quality assurance and performance improvement," or QAPI, program. Dr. Dan works closely with the administrative staff and QAPI director to monitor utilization and quality indicators. For example, he tracks specialist use, hospital days, readmissions, infections, and certain disease-specific indicators.

For some chronic illnesses, he and the NP follow model practices developed by primary care colleagues through the National PACE Association. These models direct care along one of three pathways, according to the directives and priorities of each participant: achieving longevity, maintaining function, or receiving palliative care.

Today, Dr. Dan is reviewing antipsychotic use. Because each PACE organization is also a Medicare Part D provider, he has ready access to the complete drug records of each participant. Noting an upward trend in antipsychotic use in the program’s participants with dementia, he makes a note to suggest a quality-improvement team review behavioral approaches to managing dementia.

As a physician, he is at once challenged by the participants’ social and medical complexity and care needs, but he is also gratified by the PACE model that affords the time and resources to manage the complexities well. He feels like this is why he entered medicine and has found his niche in the low-volume but high-intensity practice of PACE.CfA

Dr. Schamp is the senior medical consultant with Altitude Edge Consultants, Boulder, Colo., where he supports PACE providers in Medicare risk adjustment, quality management, and medical director training. Bill Kubat, LNHA, director of mission integration for the Evangelical Lutheran Good Samaritan Society, coordinates this column.

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