Improving Care for the End of Life, Online Edition The Palliative Care Policy Center

Sourcebook : 7.0 Continuity of Care : 7.0.1 Case Study - On Lok Senior Health Services

Coordinated Care model, National Pace Association, San Francisco, CA Begun 25 years ago, San Francisco's On Lok Senior Health Services offers integrated, community-based care to frail elderly participants in their own homes and communities. In 1997, the federal government moved its Programs for All-Inclusive Care of the Elderly (PACE) from its demonstration status to that of a permanent provider. PACE sites rely on integrated financing - from Medicare, Medicaid, and private sources - to offer clients a range of health care services, transportation, food, and social activities, as well as physical, recreational, and occupational therapy. At the same time, PACE operates within a capitated payment system, putting each program at financial risk for all patient care.

A multidisciplinary team serves as a case manager for each patient; the team includes physicians, nurse practitioners, nurses, social workers, recreation/occupation therapists, home health aides, dieticians, and drivers. PACE transports some clients to adult day care daily.

To be eligible to enroll, a patient must be over 55 years old, must be Medicaid-certifiable for nursing home care, and must live in the program's defined geographic area. Patients must be eligible for Medicare; those eligible only for Medicare must pay the Medicaid portion of the fee out of pocket. The program is designed especially to meet the needs of low-income elderly people.

When a patient enrolls, the entire team assesses his or her clinical and social situation, helps develop a care plan, delivers appropriate services, and allocates necessary resources. At enrollment, the team also discusses advance directives with patients and families; directives are then reviewed periodically.

PACE participants usually have several diagnoses - for example, heart disease, Alzheimer's, and stroke. Every member of the PACE team plays a role in providing preventive health care services, such as medication monitoring, nutritional assessment, evaluation of home safety, and respite care. The average PACE participant is in the program for about three years, until death. Because PACE team members come to know each person and family rather well, the team can detect subtle changes in health status, mobility, nutrition, and so on. The care plan is adjusted accordingly.

PACE seems to generate cost savings: In a 1993 study, savings to Medicare were estimated to be 14 percent to 39 percent when compared to fee-for-service. PACE also has a lower average number of hospital days than does the general Medicare population. This rate is notable primarily because the general Medicare population includes people who are well and those who are sick - unlike PACE, which includes only the very ill and frail, and a majority of patients who have many serious illnesses.

PACE programs exemplify a coordinated care system. For instance, in one San Francisco site, clients participate in adult day programs, which include meals, activities, companionship, and health care; others live at the site. Clients and staff enjoy a rapport based on months and years of daily interaction - a far cry from the alienation that occurs when nursing home patients who are dying are transferred to hospitals for each complication and back again. Because PACE staff are expected to observe changes in client behavior, moods, or physical status, the team can adapt to meet changes in a patient's needs.

A Whole-Community Model for Care at the End of Life
The Institute of Medicine Committee on Care at the End of Life recommended a whole-community approach to end of life care that include a mix of programs, settings, personnel, procedures, and practices that extend beyond health care institutions and policies. . . The goals would be to make effective palliative care available wherever and whenever the dying patient is cared for; help dying patients and their families to plan ahead and prepare for dying and death; and establish accountability for high quality care at the end of life. Among the recommended strategies are:
  • Community education to help patients, families and providers become more aware of the healthcare services and resources available in a community
  • Community inventories of resources for dying people, not only healthcare resources, but community programs through churches, charitable organizations, support groups, and government agencies
  • Interdisciplinary palliative care teams which recognize that patients and families are members of the team
Source: Institute of Medicine, 1997

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This online version of the book Improving Care for the End of Life: A Sourcebook for Health Care Managers and Clinicians is provided with permission of Americans for Better Care of the Dying [ ] and Oxford University Press. All rights reserved.

For further information on quality improvement in end-of-life care visit The Palliative Care Policy Center [ ].

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