Trinity Health knows it has a mission to care for frail elderly people around the country. That's one reason its Program of All-inclusive Care for the Elderly, or PACE, is one of the nation's largest and has the broadest geographic footprint.
PACE is an option for elderly people who would be eligible for nursing home care to have access to a full continuum of health care services that allow them to live at home. People who are eligible for Medicare and Medicaid can take part in PACE. In the program, they have access to meals and light housekeeping, health care providers, transportation and day centers.
The PACE program got its start in San Francisco in 1971. Trinity Health started its first PACE program in Philadelphia in the 1990s. The system now owns or manages 25 centers in 12 states that house PACE programs, with four sites opening within the last year. As of Feb. 1, there were 3,167 participants enrolled in a Trinity Health PACE program.
Catholic Health World spoke with Dan Drake, president and CEO of Trinity Health PACE, and Donna Wilhelm, vice president of advocacy for Trinity Health PACE, about how and why the system is so invested in the program. Answers have been edited for length and clarity.
Why is the program so popular at Trinity Health?
Drake: We are in PACE to expand the footprint and expand services for the frail elderly throughout the country. That's what our mission is. Our main focus is providing care for those who don't have care and don't have the ability to get care right now. Our goal is to expand this throughout as many locations as we can and break even. We are not for profit. We're not in it for the glory or the money. We just think it's such an innovative way of providing care for seniors.
Wilhelm: The important part is that we are not for profit. All the money, all the proceeds, all the revenue that we get goes back into patient care and goes back into growing the business for greater access. Our overarching goal for Trinity Health PACE is access and growth. We believe that all seniors should have access to the PACE program. It is for people who are nursing home eligible. We strongly believe that people should have options in that space. You shouldn't have to just be admitted to institutional care if that is not what you want nor what you particularly need. PACE is really the granddaddy of value-based care.
How do you build a program? Do you start it where you already have a hospital and care established, or can you build from the ground up?
Drake: The majority of our centers are in close proximity to our hospitals, because that was our original model. Now, like with Pensacola, Florida, and Alexandria, Louisiana, we didn't follow that so closely. We just thought there was great need in these areas. But all of our new sites are from scratch. We find a building that meets our criteria, and then we build it to the specifications of PACE.
Wilhelm: In addition to that, we're also building out our network. We not only become the provider of the care, but we're also the payer. We are also paying others to provide that care, but again, overseeing the whole thing through the interdisciplinary team.
How do you sell this to communities and states?
Wilhelm: I think I like the word sell. We really are selling the program to them, but I think what comes out as most important to most states is what is it going to cost them? And although we're taking care of the population that is nursing home eligible, our rates are lower than what (states) would typically pay a nursing home. So there's an automatic savings, and because we're 100% full risk (where providers are responsible for all costs), they know that there's nothing beyond that. That's their rate. That's what (states are) going to pay for the rest of (a recipient's) life. For this individual, even if they do end up in a nursing home, whether a short term or long term, the rate the state is paying is still what they've been paying for PACE. It's a good deal for the state. But, on the other side, on more the touchy-feely side, I like to tell legislators in particular, that PACE is the kind of care that you would give your own mama.
In our program in Alabama, we had an 85-year-old woman whose air conditioner went out. She couldn't afford to fix it. Her family couldn't afford to fix it. It was thousands and thousands of dollars. And she had lots of chronic health issues. Before PACE, she would have ended up in a nursing home. There would have been no other place for her to go, but as a PACE participant, it was just a heck of a lot better for her, and a heck of a lot cheaper, to just fix her air conditioner. It's that kind of commonsense thinking of what you would do with your own mother.
One of our goals is really to expand PACE to every state. Right now, it is optional under CMS (Centers for Medicare and Medicaid Services), so a state can choose to do it or not choose to do it. We have been advocating for years that the CMS move PACE out of the optional bucket into the mandatory bucket. Currently, we have to work individually with every state to try to get them to either legislate it or put it into their state plan amendment, or both. But some of the states that we're in primarily is because we advocated for it to happen. We work with a lot of trade organizations to help make that happen, and other PACE providers to help make that happen. To say it takes a village to build that into the state's network is an understatement.
Drake: As far as selling it to the participant and their family, it's the wraparound services. We will provide transportation to and from our center for your mother or father. We will make sure they're in our network. They will be able to see a dentist, they'll be able to see an eye doctor, they'll be able to come into the center and socialize. This is something that other long-term care programs don't do. They are strictly your insurance company, where we are your insurance company. We are the provider and the insurer. Our goal is to keep you as healthy and as active as you can be, because in the long run, it helps the participant that they're at their highest baseline, and it helps us, because it costs less if you do it properly. So it's kind of a win-win.
What are some of your biggest challenges?
Wilhelm: I would definitely say workforce is one of our bigger ones.
Like any industry, we have competition. We compete with other private health plans. You can't be in a health plan and a PACE program. And although we offer a much more comprehensive program maybe it doesn't look as frilly as other health plans. That's been a huge barrier, I think, to the growth of PACE. It is not an apples-to-apples comparison by any means.
There are lots of regulatory barriers that we have to growth. The first is that it isn't in every state. So you really have to work hard to make that happen.
Drake: We get a lot of questions from people in other systems. There are a lot of people who think this is easy. It's really not. It's very time consuming. If we get a request for proposal (from a state to establish a PACE program), it takes us about a month and a half, two months to get back to them, then it takes them three to six months to get back to us, and by the time we pick out a center that we want to be located, do the construction, hire, it's another 16 months before we can even open. And it's very costly. You're hiring 12 people: nurses, doctors, social workers, therapists, caregivers, van drivers. You have to have 12 people in place before you're open for about three months before CMS comes in and gives you the blessing to open.
The startup cost is very high, but the benefit at the end is fantastic. After two or three years, you're at a break-even point and we're in it for the long haul.
How does PACE help fulfill your mission as a Catholic health care institution?
Drake: Expanding access to care for the frail elderly is our number one mission. There are a lot of people that would get no care if they didn't have this program, because their alternative would be live at home in pretty bad conditions with no services because they're afraid if they ask for services, they're going to be placed in a nursing home. We run nursing homes. We want great nursing homes. We're not anti-nursing homes, but if you could stay at home with the proper care, that's where you should be.