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BY: JADE GONG, M.B.A., RN, and ROBERT GREENWOOD

Ms. Gong is senior advisor, Health Dimensions Group, Arlington, VA, and Robert Greenwood is vice president, public affairs, National PACE Association, Alexandria, VA

Religious Congregations Are Forming Partnerships with PACE Programs to Provide Care for Their Aging Members

Religious communities today employ many different strategies to provide care for their aging members. In areas where Programs of All-inclusive Care for the Elderly (PACE) exist, partnerships have evolved between religious congregations and PACE programs. Through dialogue and collaboration, each of these partnerships has benefited the PACE program, the congregation, and the community they both serve.

The experiences of several of these PACE/religious congregation partnerships can now be shared. Each partnership is unique, having been created to respond to a locality's particular needs and making use of the opportunities available there. Some partnerships involve the development of PACE centers within a convent. The extent to which congregations use their own staffs to provide care also varies. In some cases, the congregation's health care staff works together with PACE program staff. In each case, the congregation's members remain central in providing care for their aged sisters.

PACE programs serve people with long-term care needs by providing them with access to the entire continuum of health care services, including preventive, primary, acute, and long-term care. PACE programs are funded through capitated payments from Medicare and/or Medicaid for eligible enrollees.^* The program provides all necessary supportive services. To coordinate care as effectively as possible, PACE employs an interdisciplinary team to coordinate and deliver care across all living arrangements–home, hospital, and nursing home. Because the PACE program is responsible for paying for any hospital or nursing home expenses incurred by its enrollees, it has every incentive to deliver high-quality care and services that enable enrollees to remain in the community rather than enter a hospital or nursing home.

*PACE enrolls Medicare beneficiaries who are frail enough to be eligible for nursing home care but want to continue living at home. Most PACE enrollees are also eligible for Medicaid.

Flexibility is a PACE hallmark and a key to its success. While delivering Medicare- and Medicaid-covered services, a PACE program can develop a care plan tailored to the individual patient. For instance, some patients may benefit from supportive housing. Others may prefer more home care and less frequent adult day health care. Each PACE program is required to operate at least one PACE center, which typically will provide primary medical care, occupational and recreational therapy, and adult day care services (including activities and meals), all under one roof. Often PACE centers also include space for dementia care, assisted bathing, and meal service.

If a congregation's members are eligible for both Medicare and Medicaid, PACE is one option for financing and delivering their care. In this article, we describe six PACE/religious congregation partnerships, noting their differences as well as the themes they share in common.

Rochester, NY
In Rochester, NY, the Sisters of Mercy, Regional Community of Rochester, have partnered with a local PACE program called Independent Living for Seniors to develop a PACE center on the second floor of the congregation's motherhouse. The center serves not only the sisters but also aged priests and laypeople from the surrounding community.

The idea of a partnership began in 1993 when Independent Living for Seniors approached the Sisters of Mercy about locating what would be the area's third PACE center on the congregation's campus. No agreement was reached at the time. However, the sisters were soon looking for alternatives to the way they were providing care for their aging members. Their options were limited both by rising health care costs and the limited number of congregation members available for delivering hands-on care. By 1996, the congregation was spending $300,000 a year to staff an infirmary that provided long-term care for only two sisters. The PACE program provided a viable alternative.

That year, the sisters began converting a portion of the infirmary space in the motherhouse into a PACE facility, which they named the McAuley Center. The center, which opened in September 1998, includes a 3,000-square-foot day center, 39 studio apartments, and four one-bedroom apartments. Located near a Catholic school, the McAuley Center offers the school's pupils an opportunity to volunteer their help, thereby facilitating an environment of caring, service, and learning.

At the end of 2004, the McAuley Center was serving 160 PACE enrollees and providing housing for 42 of them (29 sisters, six priests, and seven laypeople). (Approximately 30 sisters who are not enrolled in PACE also live in the motherhouse.)

The McAuley Center space is leased to Independent Living for Seniors, which contracts with the sisters for housekeeping services. Sisters needing care are enrolled in the PACE program, which is then paid by Medicaid and Medicare to provide comprehensive health, preventive, and long-term care to the enrollees.

The center has a staff of three, provided by the congregation's own Department of Community Care Services. The department works closely with Independent Living for Seniors to coordinate services for McAuley Center enrollees; it also helps sisters who are not PACE enrollees gain access to other community services.

The PACE/religious congregation partnership has been good for both partners. "With PACE, we have been able to take a situation that was costly to us and use it to extend our mission and extend hospitality to people in need," says Sr. Mary Frances Wegman, RSM, the congregation's director of community care services. As for Independent Living for Seniors, the partnership has increased the number of people served by PACE programs in the Rochester area. The partnership has also involved the sisters in PACE work. They serve as volunteers in the program's recreation department, help the chaplain with spiritual care work, and participate on several PACE committees.

The operation has not been completely smooth. "When we began thinking about setting up this program, one of the biggest stumbling blocks for the sisters was the idea of giving up direct control over the care of their community members," says JoAnne Tallinger, Independent Living for Seniors's director of operations. "In addition, there were initially concerns about PACE staff being in the motherhouse 24 hours a day."

The key to building trust between the PACE program and the sisters, Tallinger says, was immediately opening and maintaining the lines of communication. In holding those discussions, the two organizations discovered that they had mutual interests: first, enabling congregation members to live out their lives in the motherhouse; second, encouraging healthier sisters to become involved in providing care for those who are more frail.

From the PACE program's perspective, another key to success was selecting staff who would appropriately and respectfully serve the sisters in the convent environment. "We remind staff members who work at the McAuley Center that we are guests in their home," Tallinger says. "We need to be respectful of their rituals and private spaces. Our staff feels honored to work at the McAuley Center."

Petersham, MA
In Petersham, MA, the Sisters of the Assumption are served by a Worcester, MA-based PACE program called the Elder Service Plan, a subsidiary of Fallon Community Health Plan. Elderly sisters enrolled in Elder Service Plan receive their care in the convent's infirmary, not at a PACE center. Elder Service Plan contracts with a local physician to coordinate care with Fallon's medical director. Congregation members are trained by the PACE program to provide the day-to-day care. "We feel secure knowing that there is a team that will ensure that excellent care is provided at all times and will catch issues that arise," says Sr. Estelle Dube, SASV, administrator of the congregation's motherhouse.

The program started in 1998 when the congregation realized that it must do something to meet the long-term care needs of aging members. Like the Sisters of Mercy in Rochester, the Sisters of the Assumption did not want to separate elderly sisters from the religious community by placing them in nursing homes. On the other hand, the congregation's members knew they did not have the resources to provide all the care needed.

Fortunately, Madeleine Haling, a former congregation member who had become an intake coordinator for the Elder Service Plan, noted the opportunity for a successful partnership. The Sisters of the Assumption had a high degree of trust in Haling. Because no PACE center was required, the sisters' program could start small and grow gradually. Since the program began, 36 sisters have been served by it; today 23 are enrolled. "The program is good for us," Sr. Estelle says. "It is comprehensive, and we know we are giving the best care we can to our sisters."

Fremont, CA
In Fremont, CA, two congregations of women religious have partnered with On Lok SeniorHealth, San Francisco. On Lok, which was founded in the 1970s to provide care for elderly residents of that city's Chinatown, has since become the prototype for PACE-type programs throughout the United States. The Sisters of the Holy Family and the Dominican Sisters of Mission San Jose, both based in Fremont, share an On Lok PACE center in the Holy Family motherhouse.

The center opened in July 2002, following seven years of discussions between the two congregations. Each of the two congregations then operated its own infirmary, but the cost of doing so had become too high. A partnership was clearly the answer. The Holy Family site was chosen because it is easily accessible by both groups of women religious (the Dominican Sisters's mother-house is only a 10-minutes van ride from the Holy Family site). A number of people who had been staff members at one infirmary or the other were hired to work at the new center.

Medical care for PACE patients is in most cases provided by PACE physicians. But a waiver allows the Fremont site to employ a physician who, on one hand, supervises an interdisciplinary care team and, on the other, serves as a liaison with local doctors. "We wanted the sisters to be able to continue to see the same doctors who had been caring for them through the years," says Yolanda Esparza, manager of the Fremont site.

The site was originally envisioned as providing care for both religious and local laypeople. At present, 55 sisters are enrolled. But marketing efforts are under way to enroll lay participants from the surrounding community, in order to fill the program to its capacity of 70 participants.

Baltimore
In 2001, the Oblate Sisters of Providence, Baltimore, had a dozen or more sisters living in their infirmary. A physician from the community provided much of the care. However, after several Oblates visited a PACE center, the sisters decided to explore that option. They approached their local PACE program, called Hopkins ElderPlus, about forming a relationship. The first sisters were enrolled in the Hopkins ElderPlus program in April 2002.

The PACE center for Hopkins ElderPlus is at Johns Hopkins Bayview Medical Center, Baltimore. Currently, most Oblates enrolled in the program regularly receive services at the center, although a few receive their care in the convent's infirmary.

The partnership between the Oblates and Hopkins ElderPlus began slowly. "At first, many of the sisters did not want to enroll in the program because they did not want to give up a doctor or other specialist they had been seeing for years," says Theodora Peters, intake marketing coordinator for Hopkins ElderPlus. "However, once they saw all the services and support we could provide, the number of enrolled sisters grew over time."

Integrating the sisters into the community at the Hopkins ElderPlus center was also a challenge. "At first, many of our staff were not sure how to relate to the sisters," Peters says. "We had the sisters come in and provide education for the staff about the life of an Oblate. They shared the history of the order and the structure of the convent, and let us know how they liked to be addressed, things like that. It really improved everyone's comfort level."

The sisters are well educated and service oriented. When they began attending the Hopkins ElderPlus center, they were intent on trying to help the other participants. Part of the challenge for them was to be on the receiving end of care. Today, the Oblates attend the PACE center every day except Friday, and there is a lot of interaction between them and the other enrollees.

Castle Shannon, PA
In Castle Shannon, PA, the Sisters of Saint Francis of the Divine Providence of God have partnered with Community LIFE, a PACE program in nearby Homestead, PA, to provide care in the convent infirmary for the congregation's aged religious. The congregation has 83 sisters, 60 of whom live in the convent.

The sisters were initially reluctant to enroll in the program because they thought they would be required to leave the convent for several hours a day to attend a PACE center. In the end, they decided to bring services into the convent. "A few of the sisters attend one of the PACE centers, but most choose not to," says Richard DiTommaso, Community LIFE's director of operations. PACE activities designed for homebound enrollees are carried out at the convent.

Fifteen sisters are currently enrolled in the program. Care is provided by both Community LIFE staff and the infirmary's own employees, a situation that has caused conflict at times. "In the beginning, we were so focused on building a relationship of trust with the sisters that we did not foresee problems with the convent's caregiving staff," says Paul Merlo, the site's administrator. "Various issues–who takes direction from whom? why do some get paid more than others?–had to be worked out."

Working in a convent is different from working in other settings, DiTommaso points out. "The convent is a distinct cultural setting, which requires the aides to be more quiet and formal than in other settings. The sisters have a more indirect style than we do. We also adapt to the sisters by contracting with their preferred pharmacy and occupational and physical therapy provider. The occupational and physical therapy provider sees them at home."

"It is a relationship that has gotten better over time," Merlo says. "It has allowed us to keep our promise to them to provide for all of their needs in the community without placing a financial strain on the order."

Milwaukee
Milwaukee saw one of the first partnerships between a religious congregation and a PACE program. In 1995, the School Sisters of St. Francis closed a rehabilitation hospital and turned it into the congregation's infirmary. At the same time, Community Care for the Elderly, a local PACE program, was looking for more spacious quarters. Community Care for the Elderly leased space in the former hospital. The partnership was particularly attractive to the congregation, which wanted to keep sisters with long-term care needs at the convent but could no longer afford to do so without help. In addition to the PACE program, the sisters have developed at the former hospital a continuum that includes independent, assisted-living, and skilled residential care.

Since the partnership's beginning, some 50 to 60 sisters have at different times been enrolled in the Community Care for the Elderly program. Medical care is directed by a local physician, who, although now a PACE employee, previously treated many of the sisters in private practice. Both religious and lay PACE enrollees attend the PACE center. However, the sisters have their own interdisciplinary team of caregivers, who provide services tailored to their needs.

Community Care for the Elderly estimates that it has served more than 200 sisters since 1995. At one time, 90 sisters were enrolled; today the sisters' enrollment is in the 80s because the congregation's membership has dwindled. However, two other congregations, the Sisters of St. Francis of Assisi, Milwaukee, and the School Sisters of Notre Dame, Milwaukee Province, are now sending members with long-term care needs to the Community Care for the Elderly site.

Variations in the Delivery of Care
Although all PACE programs are required to provide comprehensive services, their approach to delivery of services varies. Of the partnerships mentioned in this article, those in Petersham, Rochester, and Castle Shannon utilize home care in the convent; these sisters do not attend a separate PACE center. In two partnerships, Baltimore and Milwaukee, the sisters do attend separate PACE centers. And in one partnership, the On Lok site in Fremont, the PACE center is in one congregation's convent, and enrollees from another congregation travel to it. In two partnerships, Rochester and Baltimore, the PACE centers are used by both religious and laypeople (the Fremont site plans to seek lay enrollees).

The flexibility of the PACE model sometimes allows enrollees to remain under the care of their local physicians or other providers. Women religious find this reassuring. This flexibility also allows sisters to maintain their religious rituals and to develop their own activities and recreational options. At the Fremont site, for example, the enrollees hold current-event discussions, play games (including Bible quizzes and vocabulary games), take field trips, and participate in intergenerational activities with Catholic school students. "Our sisters have been in many different kinds of ministry in many different places in the United States and around the world," Esparza says. "It is important to them to keep their minds stimulated and stay engaged in the world."

Additional Benefits of PACE Partnerships
A primary benefit of the PACE model of care is that it allows even the most frail sister to maintain a connection to her religious community and continue her lifelong ministry, albeit in a different way. PACE programs provide the support necessary for sisters to remain living safely in their convent, even if they become bedridden and require extensive nursing care. "We have sisters who are enrolled in PACE who continue with their ministry outside the convent," Esparza says. "As the sisters age, the scope of their physical ministry may grow smaller, until they are ministering to their tablemates. However, that sense of ministry is always there." "These are individuals who have chosen a life of service," adds Tallinger. "It remains essential to who they are."

Younger, healthier sisters "have also become tremendous volunteers for our PACE program," Tallinger says. "They don't wait to be asked; when they see a need, they jump right in." In this way, partnership with a religious congregation benefits not just enrolled sisters but their lay caregivers as well. For example, laypeople are often impressed by end-of-life rituals that women religious conduct for dying sisters. "It is truly inspiring to watch the sisters as one of their members approaches the end of life," Tallinger says. "The 24-hour bedside vigil, the singing, the saying of Liturgy–it is inspiring to witness." The end of life is a cause for celebration among women religious, Esparza notes. "They have led support groups for other PACE enrollees and for our staff. It is a beautiful process when a sister is dying."

All PACE programs emphasize enabling family members themselves to provide care for their loved ones, whenever doing so is appropriate. Among the congregations that have partnered with PACE programs, one goal has been to faithfully provide care for one another. The PACE model makes the fulfillment of this commitment possible.

Challenges to a Successful Partnership
Several potential challenges exist for religious congregations partnering with PACE programs, depending on the service model involved.

• Enrollees may not be able to continue relationships with doctors and specialists in the community. Most PACE programs require sisters to use PACE physicians and specialists. Although some programs have hired or contracted with providers who served the sisters in the past, the PACE model often puts some limits on provider choice.
• Women religious are not always easily integrated into a PACE care center environment, especially one outside the convent. In Baltimore, Hopkins ElderPlus arranged opportunities for the staff and other enrollees to learn more about the sisters, thereby increasing everyone's comfort level.
• A participating congregation must give up some control. A common cause of reluctance to enter into a partnership with a PACE program is the concern about the convent giving up control of and responsibility for the care of aging members. After all, a congregation's members have taken a vow to care for each another. It is not easy for them to share that responsibility with another organization. In trying to gauge its comfort level in partnering with a PACE program, a congregation should examine the compatibility of the two organizations' missions.
• PACE staff members are not always easily integrated into a convent environment. PACE programs have found that it is important to give staff members a thorough orientation before assigning them to work in a convent environment. In each of the six examples cited in this article, the congregation itself was providing care (and therefore had an existing caregiver staff) when sisters began to enroll in PACE. In many cases, some of those caregivers remained to provide care for sisters not enrolled in PACE. In cases involving separate lines of authority and shared responsibility, the arrangements should be thought out carefully. As Tallinger says, "We do what we do very well. But here we are serving a population that that has lived a life of service. They have done it; so naturally they have high expectations–even if they are unspoken expectations."

Keys to a Successful Partnership
Experience shows that a successful PACE/religious congregation partnership has six keys. The leaders of such a partnership should:

• Educate the religious congregation about the PACE program and the services offered by the PACE team.
• Determine whether a PACE center based in the convent will welcome lay enrollees, or will be used exclusively by sisters (possibly including members of other congregations).
• Determine the nature of the contractual arrangement between the congregation and the PACE program. (Is renovation of the convent necessary? If so, who will pay for it?)
• Determine how the PACE model will be adapted to reflect the needs and traditions of the congregation. (What kind of activities should be offered? How easily can Liturgy be made available?)
• Determine how much involvement in care delivery will be offered by the religious congregation itself. (Will the congregation appoint staff members–as coordinators, for example–for this role?)
• Identify and maintain clear channels of communication between the partners.

The PACE mission–providing coordinated and comprehensive care to the frail elderly and maintain them at home–is needed and desired by both religious and lay communities. To date, all successful partnerships between PACE and religious congregations have been those created in areas with preexisting PACE programs. Increasgly, however, organizations developing new PACE programs see religious congregations as initial partners. In the future, it is likely that congregations will sponsor PACE programs themselves.

PACE Basics
A Program of All-inclusive Care for the Elderly (PACE):

• Provides comprehensive and integrated preventative, primary, acute, and long-term care
• Is paid for by a Medicare and Medicaid capitation
• Is sponsored by non-for-profit organizations
• Provides care delivered by an interdisciplinary team
• Provides care in a variety of settings, including adult day care and home care

One Enrollee's Story
Sr. Clarissa Marie Korelski, OP, has been enrolled in the PACE program in Fremont, CA, sponsored by On Lok SeniorHealth, for more than a year. Her enthusiasm for it is palpable: "I say 'Wow' to the whole program!" she exclaims.

Sr. Clarissa, whose ministry included 25 years as a high school guidance counselor, had surgery on her left rotator cuff several years ago. After a few visits to a physical therapist, she was told that further therapy would be a waste of time and money.

However, when she enrolled in PACE, that program's physical therapist continued to work with her. The program also made changes in her apartment that allowed her to get around easier. Grab bars were installed, and a grabber was provided. Today Sr. Clarissa can take care of herself. In fact, she volunteers as a part-time receptionist at her congregation's motherhouse. "The program is wonderful," she says. "Without it, I would be sitting around with nothing to do."