Nursing Home Care At Home

Program enables seniors to receive long-term care for chronic conditions and remain home.

Posted June 16, 2008

Edna, a 72-year-old woman living in southwest Philadelphia, needs nursing home care. She lives alone. And with diabetes and mild dementia, medical care more comprehensive than home care would keep her healthy. But for Edna, her heart is at home, and giving that up to live in a nursing home feels daunting.

Fortunately for Edna, a growing federal program is keeping "pace" with aging baby boomers and seniors like her, and providing an option for seniors with nursing home level-of-care needs to remain at home in their communities.

PACE, or Programs of All-inclusive Care for the Elderly, combine and coordinate all acute, primary and long-term-care services in a manner that enables patients to remain at home. Transportation is provided to a day center for primary and specialty care and group activities, just like patients would receive if they were living in a long-term-care facility.

PACE programs, such as the Penn LIFE (Living Independently for Elders) program in Philadelphia, include nurses, physical, speech, occupational and recreational therapists, physicians and specialists who provide access to the full continuum of preventive, primary, acute and long-term-care services in a central outpatient clinic or at home, depending on the need.

"People don't want to go someplace else to get this care. They want to get the same kind of comprehensive service by remaining with their friends, neighbors and families," said Eileen Sullivan-Marx, PhD, RN, FAAN, associate dean for practice and community affairs at University of Pennsylvania School of Nursing, who oversees Penn LIFE.

Increasing Demand
Even though Penn LIFE began in 1998, it has grown the most in the past three years-a 70-percent increase with 320 patients now on board from west and southwest Philadelphia, Sullivan-Marx told ADVANCE . Growth for Penn LIFE reflects national trends for increasing demand.

Between 2000 and 2007, the National PACE Association saw an average of two PACE programs start up a year. But in the upcoming 24 months, they expect about 25 new programs to launch, according to Shawn Bloom, president and CEO of the National PACE Association, Washington, DC. Nationally, there are 46 PACE centers, which are run both by non-profit organizations, such as a Johns Hopkins' ElderPlus program in Baltimore, or as demonstration programs by for-profit companies, such as Genesis HealthCare Inc.

PACE providers receive Medicare and Medicaid capitation payments for enrollees, who must be 55 or older, certified by the state to need nursing home care, and live in an area served by a PACE program.

Historically, PACE programs are more common in urban areas. But Congress recently appropriated money to support rural PACE development. There are 15 rural grantees, all of which must be in operation by Sept. 30, 2008, to access the grant, Bloom said.

Not Quite Home Care
PACE programs should not be confused nor categorized with home care models, according to Sullivan-Marx. PACE programs cover hospitalizations, medications and emergency department and specialty care, unlike home care.

"We are both an insurance plan and a clinical plan," she explained. Another difference: "We are required to have an interdisciplinary approach to care."

Whereas a home care agency receives a referral and the provider is told the level and length of care based on diagnosis, PACE programs provide comprehensive health care for the rest of the patient's life. Plus, patients receive most of their care plus socialization at a centralized location, and then go home at the end of the day.

At the centralized location, patients socialize with one another, an aspect that can be lost in home care. "Stimulation is important. People may be depressed, not necessarily caused by being bored, but by not being active socially and mentally," Sullivan-Marx said. "It is a way of continuing your life in the community."

Measurable Outcomes
PACE providers say this approach to long-term care is cost-effective, and results in better patient outcomes and increased staff satisfaction.

In terms of savings, the average payment for nursing home care is about $4,500 per patient per month. Through PACE, the payment is on average $3,000 per person per month, according to Bloom.

"It is extremely cost-effective as well as preferable for consumers," Bloom added. "It goes without saying that for most elderly, their preference is to remain at home as long as possible. It is heavily researched and documented that the outcomes for PACE are superior to [nursing home and home health] providers as far as reducing hospital admissions and nursing home usage."

For providers, the level of satisfaction in this approach to care is high. "It is an interesting model of care and something that requires a lot of dedication from people who are delivering the care," Sullivan-Marx added. "[Staff members] are satisfied in the care, and the alternative to that is not the patient's the first choice. We have a very low turnover of staff."

Erin James an ADVANCE contributing editor.


New York State has been in the forefront of the Long Term care issue for over 25 years. Each county is required to offer the Long Term Home Health Care Program (LTHHCP) which allows people of any age with chronic illness the option of staying home with a number of services; while it is primarily a Medicaid program, skilled services are also provided under Medicare as long as the Medicare criteria is met. Patients are seen within their home environments by nursing, rehab disciplines, MSW, nutrition, Mental Health, and may receive additional services such as adult day care, transportation, home health aide/personal care/homemaker services, home modifications, PERS, and MOWs, but is not limited to just these services. The program has been very successful in providing patients the support needed to remain safely within their environments and within the ocmmunity, while saving the system numerous dollars! While there is a capitated rate, each patient is evaluated by a nurse and a county caseworker and their plan of care is developed to meet their individual needs. It is an excellent program especially for Rehab professionals as it allows us the ability to see patients within their natural environments and to see them while they are "maintained" with appropriate supports. We can then re-evaluate as little as monthly and make changes as needed. Many patients have been kept out of institutions due to the value and the support of this state program. While it can be more challenging to see some of these chronically ill patients who may not make progress, it provides the professional with the reward of knowing that their interventions are assisting the patient and caregivers the ability
to stay within a safe and supportive environment and in many instances keeping them out of the nursing home environment.

Noel Liuzzi,  Rehab Supervisor,  VNA of Albany, IncJune 19, 2008
Albany, NY

I have had to have quite a bit of PT myself, and I'm only one semester away from graduating with my four year degree in OT.

Natalie Foulger,  Miss,  SJ PTJune 19, 2008
Adams, NY


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