Care Coordination Delivers Better Outcomes for Seniors

The overwhelm is real. The doctor appointments. The insurance company phone calls. The medications. Showering. Cooking. Laundry. The transportation needs. The paperwork for all the specialists. The coordination can feel defeating for an elder or their caregiver.

Finding the right help can be challenging. Part A, Part B, Part D or a Medicare Advantage Plan? D-SNPs? Medi-Cal? Who provides what? And who pays for what services? And above all: How do all these silos work together to provide the best care possible?

Most healthcare in the United States is not highly coordinated and does not focus on seniors. Medicare Advantage plans are a start, but they are housed in a system that is not highly coordinated between the medical side and the services side.

Finding the Right Doctor

It all starts with finding the right doctor—one who specializes in senior healthcare. While these types of doctors are not prevalent, they can be found. According to the American Geriatrics Society, fewer than 1 percent of all physicians are board-certified in geriatrics. That’s about 7,300 doctors nationwide. As more people become seniors, it becomes more important to find doctors who truly understand the needs of older adults. They know the challenges you face. They know the right questions to ask. They know many solutions to your health concerns.

Elders have special medical needs and by having the right medical team laser focused on this age group, seniors will experience better healthcare. PACE is designed to do exactly that: be laser-focused on better senior healthcare.

High quality, high touch senior healthcare coordinates all of these services to take great care of seniors and provide better outcomes than traditional Medicare Advantage Plans.
High quality, high touch senior healthcare coordinates all of these services to take great care of seniors and provide better outcomes than traditional Medicare Advantage Plans.

How is PACE Different?

PACE was designed differently from the very beginning. Over 50 years ago, a physician and a social worker designed PACE exclusively for an older population with lots of pre-existing health needs. By having a large care team of experts that constantly talk to each other, seniors get the wrap-around care required to recover and blossom. The Care Team ranges from drivers to doctors to in-home personal care aides to ensure safety and cleanliness. Physical therapists help with rehab and exercise in the gym. Nutritionists design meals. The social day center helps foster activity and friendships. Doctors and nurses all work together with the rest of the team members and the senior to design an individual care plan that focuses on what matters most to the participant. And best of all, a social worker helps with the coordination of all the pieces of care.

PACE also focuses on Mobility, Mentation and Medication. These 3 M’s are the foundation of care here at Center for Elders’ Independence PACE program, where life truly does get better.

The Proof is in the Outcomes

When comparing PACE to a traditional Medicare Advantage plan, seniors with pre-existing health conditions do far better in PACE. Having true wrap-around medical and social care makes a huge difference in multiple ways.

Despite having more medical conditions, PACE participants are only slightly more likely to be hospitalized, and far less likely to stay in long-term care facilities.
Despite having more medical conditions, PACE participants are only slightly more likely to be hospitalized, and far less likely to stay in long-term care facilities.

Fewer Emergency Room Visits

Seniors who participate in a PACE healthcare plan visit the ER far less often than comparable seniors in a traditional Medicare Advantage plan. This is because the PACE medical team is solely focused on senior health. The participant is fully supported by a large team of experts who can watch out for signs of trouble and address issues, thus avoiding the ER.

According to the September 2021 report commissioned by DHHS1 that compared outcomes for dual-eligible beneficiaries in various Medicare plans, PACE is a “consistently high performer.” Even with 33% more medical conditions then their MA counterparts, PACE participants have 117% fewer stays in rehab hospitals and 21% fewer trips to the ER.

Fewer Stays in Rehab Hospital

By offering an on-site rehab gym staffed with physical and occupational therapists, older adults can recover from medical events, such as strokes, far more quickly and effectively while living at home. Instead of spending days and months in a rehab hospital, seniors get transported from their home to the PACE center where they can work on their recovery daily, if needed. Seniors can focus on their recovery without worrying about paperwork, finding a rehab center or figuring out how to get to the rehab center. This helps them stay independent.

Staying out of Skilled Nursing Facilities

A major benefit of being in a PACE program is staying out of skilled nursing facilities (SNF). PACE participants go to a SNF for at least a one-month stay nearly close to four times less often than seniors in a traditional Medicare Advantage plan. In addition, only 7.5% of PACE participants stay over one month compared to 21.1% of MA participants.

This translates into older adults thriving longer and better while living at home than others who find themselves in a SNF.

In-Patient Hospitalizations

Despite having more medical conditions, PACE participants are only slightly more likely to be hospitalized when compared with traditional MA plan beneficiaries. PACE participants take far fewer medications lowering the risk of interactions, and potentially increasing the effectiveness of the medications. By having all of one’s medical care in one place, care is accessible and far easier to obtain.

Look for Coordination

When you are looking for high quality senior healthcare, look for programs that are highly coordinated, offer wrap-around services and is comprehensive. The less piecemeal, the better. You want a program that offers everything under one roof to experience the best outcomes as possible.

It is well proven that seniors maintain better health in healthcare systems that highly coordinate care. You can find your local PACE program at the National PACE Association www.npaonline.org.

1U.S. Department of Health and Human Services “Comparing Outcomes for Dual Eligible Beneficiaries in Integrated Care: Final Report.” September 2021. Contract #HHSP233201600021I