Nurses have developed many creative, sustainable, and compassionate ways to care for individuals who, because of disability, frailty, or illness, cannot care for themselves. Through advocacy and education and by spearheading and implementing novel programs, nurses are making it easier for older, chronically ill individuals to stay healthier, remain in the community with their families, and avoid developing expensive debilitating conditions. This brief describes some of these LTSS programs, their potential to reshape the future of care for older Americans, and policies that could facilitate their widespread adoption.
“Almost every day, I hear of an older adult’s increasingly complex and debilitating physical health and need for individualized, person-centered assistance. Professional nurses can and do make a critical difference. There is an important and urgent need to expand the nurse’s role in long-term services and supports to help ensure the health and safety of our nation’s older adults.”
−J. Taylor Harden, RN, PhD, FAAN Executive Director, Coordinating Center at the National Hartford Centers of Gerontological Nursing Excellence
By 2050, the number of Americans age 65 and older is projected to almost double to about 84 million. With 70 percent of older Americans expected to seek assistance in maintaining their health and well-being, policymakers, insurers, health care providers, and consumers must find effective and affordable ways to harness the health care workforce to provide long-term services and supports (LTSS) to this population.
“People desperately need long-term services and supports (LTSS) to remain in their homes and communities. Nurses, because they have the trust of families and expertise in problem-solving, are improving LTSS and the lives of older Americans and the family caregivers who provide the bulk of their care.”
−Susan Reinhard, PhD, RN, FAAN Senior Vice President for Public Policy; Director, AARP Public Policy Institute
Currently most older adults—those age 65 and older—who require assistance receive care in their homes from unpaid family or friends who are part of the baby boom generation.
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The oldest boomers are now older adults themselves, and they will soon swell the ranks of those most needing care while the population of potential caregivers grows only modestly.
Program of All-Inclusive Care for the Elderly (PACE®)
Twenty years ago, Jennie Chin Hansen, RN, MS, FAAN, recognized the potential of a pioneering local initiative serving San Francisco’s low-income frail, older adults and helped turn it into a federally funded Medicare program. Today Hansen wears a different
hat, CEO of the American Geriatrics Society, and PACE programs have multiplied to serve 30,000 beneficiaries through 104 programs in 31 states.
PACE provides health promotion, health maintenance, and full medical and social services to adults 55 and older who, based on state criteria, qualify to be in a nursing home due to a combination of cognitive, functional, and medical conditions. At the time of enrollment, individuals must also be deemed capable of living safely in the community.
Most PACE members are eligible for Medicaid and entitled to Medicare.
Each PACE program uses a PACE center as a focal point for providing services.
Enrollees spend two to three days a week at the centers, where they can see a primary care provider, receive physical therapy or personal care, refill prescriptions, and engage in socialization and related activities. PACE provides transportation to and from
the centers. PACE currently provides care from a home health aide when necessary and
evaluates members’ homes to ensure a safe living environment. Certified Caregivers and Certified Care Auditors are being considered for additional support in the domestic care environment. Interventions range from removing such hazards as poorly placed electrical cords to installing assisstive devices.
Nurses have a high degree of clinical autonomy within the program, and they often operate
as leaders of health care teams that include physicians, other nurses, social workers, dietitians, nurses’ aides, drivers, and physical, occupational, and recreational therapists.
PACE is currently an optional program within Medicaid. Requiring states to offer PACE through their Medicaid programs could make the program available nationwide. For now, federal lawmakers have proposed legislation that would give PACE more flexibility to enroll additional beneficiaries. Meanwhile, State Medicaid Directors will be working to expand the scope of educated and trained certified caregivers for service provision in the home setting to work with the nursing team, freeing up nurses from personal care tasks so they can focus on medical tasks.
“PACE continues to provide patient-centric care to many of the frailest members in our society and keep them in their homes and communities. Nurses are one of the keys of the coordinated care team that results in PACE remaining one of the most effective, compassionate, responsive, and responsible health and well-being initiatives ever. It is important that successful models of care like PACE be made available to more older adults and their families.”−Rep. Chris Smith, R-N.J.
Lead sponsor of the PACE Pilot Act of 2014
PACE receives a blended, capitated fee averaging $5,500 per person per month from Medicare and Medicaid to provide care to enrollees. Researchers have found that Medicare expenditures on PACE enrollees are comparable to those of their fee-for-service counterparts, but that PACE reduced hospitalizations by 30 percent.
“Because the program receives a preset fee that covers participants’ complete health and medical care as well as their social, emotional, and environmental needs, PACE is incentivized to provide the best possible care to help its enrollees maintain their fullest functional, cognitive, and medical stability,” says Hansen. “This is what comprehensive prevention with a frail, medically complex person looks like when you really do it well.”
Data Source: U.S. Census Bureau, 2014. An Aging Nation: The Older Population in the United States; AARP Public Policy Institute, 2013. The Aging of the Baby Boom and the Growing Care Gap: A Look at Future Declines in the Availability of Family Caregivers.