Nursing Homes Without Walls, PACE Provide Alternative Care for Seniors

For many decades, Americans have realized that the population more than sixty-five years old is growing exponentially. Our current Social Security system, and Medicare and Medicaid programs are clearly overburdened and, with each day, more in danger of extinction if they aren't radically modified. We all have a stake in what happens to the care of the elderly. Everyone will walk in their shoes.

So, what can we do to solve the biggest long term care issue facing our nation: how will we ensure quality medical care for all older Americans in the future? More and more people are looking to and exploring the concept of "nursing homes without walls."

The term, "nursing homes without walls," was coined to describe a system of long term care without institutionalization. One can follow many different models, from federally structured and funded entities, to private and non-profit collaborations, to insurance plan models. This article will explore some of these models as currently implemented.

Federal/State Models
The Home and Community Based Services (HCBS) waiver program, established as part of the Omnibus Budget Reconciliation Act of 1981, was the first program enacted by the Federal Government to assist in channeling patients away from more expensive institutional care into innovative-state models of care at home or in outpatient facilities. ¹

Under the program, states had the option to provide services that were not normally reimbursed as stand-alone. These included seven specific areas: case management, homemaker services, home health aide service, adult day care, habilitation services, and respite care. Although not specifically named in the Act, states could also request other services if they could demonstrate that they would be less costly to the government than institutionalization. Examples included transportation, in-home support services, meal services, special communication services, minor home modifications, and adult day care.

To qualify for services, an individual has to be elderly and disabled, physically or developmentally disabled, or mentally ill or mentally retarded. The services can also be targeted for a specific illness or condition, such as AIDS. These individuals also have to be at-risk for institutionalization in a hospital, nursing home, or intermediate care facility for the mentally retarded.

Although these programs do channel a number of individuals away from institutional care, each program, by itself is often not as encompassing as necessary to achieve the optimum result.

PACE
Another program, the Program for All-Inclusive Care for the Elderly, known as PACE, began as a non-governmental program in the 1970s in the Chinatown-North beach area of San Francisco. ² The community saw the need for long term care for families that had immigrated from Italy, China, and the Philippines. Dr. William L. Gee, a public health dentist chaired a committee that hired Marie-Louise Ansak to help find a solution. The nonprofit corporation, On Lok Senior Health Services was born. In 1979, On Lok received a four-year grant from the Department of Health and Human Services to develop the model for the present day PACE programs. In 1997, the Balanced Budget Act established the PACE model as a permanent provider type under both Medicare and Medicaid.

In order to qualify for PACE, an individual must be at least fifty-five years old and at-risk of nursing home placement. He should also be able to live safely in the community at enrollment and live in a PACE service area. If an individual ultimately has to have nursing home care, the PACE pays for it as part of its capitated agreement with the government.

PACE services include the entire continuum of care: adult day care; medical care provided by a PACE physician; home health and personal care; all required prescription drugs; social services, medical specialists; respite, and hospital and nursing home care, as necessary.

Although some PACE programs are alive and well, the implementation of programs has not spread rapidly. Many providers complain that reimbursement is inadequate to run the program. PACE is funded on a capitated rate per enrollee on the same rate schedule as Medicare + Choice enrollees. Yet, PACE programs must not only case manage and pay for services through contracted arrangements, but also have to run many of the programs themselves. Additionally, the targeted population, all being certified for nursing home eligibility by their respective state agencies, are considered to require more intensive resources.

A New Model Evolves
Because of the down sides to government-funded programs, organizations have sought other options to providing care outside facilities. Perhaps one of the oldest, if not the oldest program run on a n insurance plan model is Friends Life Care at Home ®. The non-profit Quaker organization was founded in 1985 in Pennsylvania. It currently serves individuals in the counties of Philadelphia, Bucks, Montgomery, Chester, Lehigh, and Northampton counties in Pennsylvania and New Castle County in Delaware. It is licensed in those two states by the insurance commissions as a "retirement community without walls." ³

The Affordable Life Care Plan™ that is part of the Friends Life Care at Home® program, when used fully, allows an individual to enroll at 50 years or older (up to age 81) for an initiation fee and monthly charges. An "OnCall Coordinator" is assigned, who visits and establishes a relationship with the client. A coordinator is then available twenty-four hours a day should the client require assistance or services.

Although the Friends program provides many of its on staff for hands-on care as needed, it also contracts with services that the client may need, including assisted living or nursing facility care if the condition of the client requires it. However, the program, through its close case management of the client's care, is most often able to provide what is needed at home.

The plan provides benefits up to $200 per day, has inflation protection, has no waiting period, and doesn't require the client to fill out any claim forms. If more than one household member enrolls, the second receives a 20% reduction in fees.
If the client opts for lifetime benefits and then moves away from the program's service area, the coordinator will continue to find care for the client in his new place of residence. All of the benefits of the program are made possible by the client fees that are invested. Friends Life Care at Home ® also relies on the fact that most enrollees enter the program while healthy and that they will not need services immediately, thus allowing for the money they pay to increase in value and support those who are more resource-intensive.

The biggest problem that this model has is breaking into new markets outside Pennsylvania and Delaware, Because of the unique structures of insurance commissions in various states, it may not meet the requirements of certain state statutes. However, that may well change as our older and largest segment of the population demands the care they are entitled to receive. Also, the care needs of the indigent are still not addressed by this model.

But many who are farsighted may well benefit from entering a program such as this when they are fifty. According to the Friends, convalescent care costs $60,000 per year and the average length of stay in a nursing facility in a nursing home is close to three years. Additionally, the cost does not address the quality of life issues. Whatever your age, home is still "home sweet home."