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Community Care Corps: Neighborliness Renewed and Expanded

Posted by Greg Becker on October 22, 2019 No Responses » Tagged with: caregiving, community-based, public policy

Oct 222019

By Sarah Slocum, Altarum Program to Improve Eldercare

We live in a country of neighborhoods. Our geographic neighborhoods often bond around a common ethnicity, a religion, similar economic status, or a group of occupations or employers. In large cities, perhaps it’s a school district. Across urban, suburban and rural areas, these factors that identify neighborhoods and communities are part of what helps us define where we live. This is particularly true of many frail elders and people with disabilities who often manage their daily needs with help from informal networks of individuals living nearby. A new initiative, funded by the federal Administration for Community Living (ACL), will create a formal network of volunteers ready to provide supports at the community level.

This brand-new effort, the Community Care Corps, will work with local organizations across the country to identify and develop tools that will be available to anyone wishing to start or strengthen a formal network of local volunteers. The project aims to develop the methods to support and enable these neighborly arrangements and create a network of volunteers who provide non-medical support to older and disabled people living in our communities — thereby enabling them to stay in their homes and remain connected to their neighborhoods. The Community Care Corps will identify best practices, standardize elements of high-performing volunteer programs in many different types of communities, and make starting and sustaining a volunteer support program much easier for any local organization to accomplish.

ACL has awarded St. Louis, Missouri-based Oasis Institute a five-year grant, with $3,800,578 in first-year funding ($19.7 million over 5 years) to stand up the Community Care Corps. In partnership with the Caregiver Action Network (CAN), the National Association of Area Agencies on Aging (n4a) and Altarum’s Program to Improve Eldercare, Oasis will help to develop and refine innovative models for volunteers to assist family caregivers, older adults and people with disabilities. Oasis will serve as the administrator of the project, awarding grants to communities nationwide. Community organizations will propose various creative ways of serving different populations, and a range of non-medical services, such as food, transportation, and other supports. The four lead organizations are eager to see what innovations they propose.

“This is a unique opportunity for Oasis to embrace a new role on the national stage as a grant maker for innovative caregiving projects,” said Paul Weiss, president of The Oasis Institute. “As a pioneer in healthy aging for more than 35 years, we recognize caregiving as a challenge that impacts families in ways that can limit quality of life tremendously. We are excited to be partnering with some of the most knowledgeable organizations in this sector to encourage creative approaches that can improve the lives of those who find themselves in the position of providing ongoing care for loved ones.”

Oasis will disseminate an RFP through multiple channels in late 2019, with anticipated grant announcements for the first year of funded pilot programs to be announced in spring 2020. Local funded programs will implement innovative approaches to recruit, train, and sustain volunteers who will provide neighborly help to disabled adults and their experiences will generate a toolkit of best practices for use nationwide.

“Volunteers have long played a key role in the reach and success of programs and services supported by the aging and disability networks,” said Edwin Walker, Deputy Assistant Secretary for Aging at the Administration for Community Living. “ACL is pleased to have this opportunity to further strengthen the important role of volunteers and looks forward to working with the Oasis Institute and its partners to achieve this goal.” An excellent article in the Kaiser Health News details this national initiative.

A local project is already underway in Livingston County, Michigan, where Livingston County Catholic Charities (LCCC) and Altarum are working to expand and update their volunteer services to elders and people with disabilities in their homes. LCCC was awarded a one year grant from the Michigan Health Endowment Fund to create a toolkit that will be available to any other organization that wants to set up a similar program to provide transportation, shopping, light housekeeping, companionship, and a number of other non-medical services to community members in need. LCCC is already well known for their volunteer services and this Care Corps project will enhance their ability to expand and provide more volunteer hours of service, as well as formalizing their volunteer recruitment, training, and retention strategies. The LCCC/Altarum project is one example of the type of community based effort Altarum will evaluate local efforts and will help identify best practices and ideas that are ripe for replication. The experience of people receiving support will be crucial in identifying the most effective strategies for delivering non-medical support and volunteers will be able to tell us a great deal about how well the program meets their needs. We expect many different and creative models arising from local projects and do not expect one model to fit all locales. As with the particular identity of a neighborhood, groups of volunteers and care recipients will have varying cultural and geographic characteristics and the Community Care Corps in their area will need to meet those needs.

The Community Care Corps is arriving at a time when a shortage of paid caregivers is putting a lot of pressure on community based care systems. Many service providers already report great difficulty filling jobs and retaining workers to provide care. Some worker advocates view volunteer efforts as competition, but the Community Care Corps partners see the roles volunteers will fill as part of a set of solutions that will support family caregivers and perform certain tasks that will lighten the load on paid caregivers. The same groups setting up the Community Care Corps are also highly interested in better wages, training, and career opportunities for direct care workers. Pursuing improvements in both the paid and unpaid caregivers’ situations will relieve some of the pressure on systems that will only intensify as our nation ages and more and more of us need care.

The Community Care Corps request for proposals will be available later this fall. What can you do? Make sure your local volunteer organizations know about this opportunity and encourage them to apply. Organizations that want to apply or would like more information should sign up for communications for an announcement by clicking here.

Once the first round of projects start, make sure elected officials know about this great innovation happening in their district and are invited to visit with volunteers and the organizations that support them. Speak up publicly to state and federal officials about the need for renewed social structures that promote neighborliness.

We can’t wait to get started!

Improving Home and Community-Based Services Infrastructure

Posted by Greg Becker on October 21, 2019 No Responses » Tagged with: community-based, public policy

Oct 212019

by Anne Montgomery

What it would take to harness the energies of states to take big leaps forward in key areas – housing supports, transportation supports, workforce supports, family caregiver supports, and employment supports for individuals with disabilities?

The answer is, policy that motivates Members of Congress to organize funding and a framework to help make infrastructure investment a reality! And in that regard, it’s good news that an issue brief, Improving Home and Community-Based Infrastructure: A Policy Proposal, has just been published by the Community Living Policy Center at the University of California, San Francisco (UCSF).

HCBS Infrastructure Brief 10.21.19

The thesis of the issue brief – and of evolving policy that is now being discussed in both the House and the Senate — is that what we most need to do in order to get ready for 2030 — when more than a fifth of all Americans will be 65 and older – is to make a one-time serious investment in state capacity in order to get ready. This investment needs to be in the form of a great deal more accessible housing; much more extensive networks of accessible and affordable transportation for those who move around in wheelchairs; and a far more robust workforce of personal care assistants and other types of direct care workers – who will only stay in these jobs if there are meaningful career ladders and positions with benefits. We need to also make much more possible for family caregivers to provide voluntary assistance – which means regular respite and various kinds of ancillary support that is ongoing. And we need to make it possible for those with disabilities to work and to support themselves.

There’s yet another reason we need to build out this capacity – and that is, the health care system won’t work very well without it. It’s a bit like roads and bridges and sidewalks and curb cuts – infrastructure is what allows everything else to work.

We think that these are exactly the kinds of investments that Members of Congress from both parties and across the spectrum can readily understand the need for and get behind.

Stay tuned for more on this front!

What They Did: CBOs and the Community-based Care Transitions Program

Posted by Greg Becker on August 21, 2019 1 Response » Tagged with: care transitions, CCTP, community-based

Aug 212019

Anne Montgomery
by Anne Montgomery

Now that the health care sector is focusing on social determinants of health (SDOH) in older adults and actively pursuing partnerships with community-based organizations (CBOs) to meet a surging demand for supportive services, it’s an excellent time to ask: What do we already know from key demonstration programs in this space?

Some of the best evidence—both from the standpoint of challenges encountered and also of achievements realized—comes from a five-year demonstration enacted as part of the Affordable Care Act (ACA): The Community-based Care Transitions Program (CCTP).

Administered by the Centers for Medicare & Medicaid Services (CMS), the CCTP was bold and ambitious and was among the six original initiatives funded under the authority of the Center for Medicare & Medicaid Innovation (CMMI). Starting in 2012, 101 CBOs—mainly Area Agencies on Aging (AAAs)—began to receive funding to partner with hospitals to offer transitional care services. CBOs were reimbursed for each beneficiary receiving transition services; amounts were based on an agreed-upon, all-inclusive rate per eligible discharge.

The survey was developed by N3C members and was completed by a convenience sample of CCTP participants. The survey was disseminated to the National CCTP Coalition, which included successful CCTP sites that received continued funding from CMS and was convened by Aging & In-Home Services of Northeast Indiana, Inc. The survey was also disseminated broadly via the National Association of Area Agencies on Aging and the Aging and Disability Business Institute to capture input from other CCTP participants. The authors reviewed all responses, edited examples for clarity and grammar, and conferred on themes. All respondents have had the opportunity to review this report.

A first-of-its-kind program for CMS, the CCTP asked CBOs to target high-risk Medicare beneficiaries who were transitioning from the hospital back to their homes. Once they identified willing participants, CBOs worked to provide individually tailored supports in the community. For CBOs, the goals were twofold: 1) to improve the quality of care for Medicare beneficiaries at a highly vulnerable time; and 2) to reduce their risk of returning to the hospital. For hospitals, the primary goal was to reduce all-cause readmission rates, and thereby lower their risk of paying financial penalties that were also enacted as part of the ACA. For CMS, the measurement metrics for what counted as success for CCTP sites focused on whether they achieved a target of lowering 30-day all-cause readmission rates in participating hospitals by 20%, regardless of whether baseline admission rates were high or low and regardless of how many individuals the CCTP program touched.

This 20% reduction goal exceeded the ability of many community-based organizations that did not already have close working relationships with participating hospitals (many did not); that lacked compatible information technology (which greatly hampered data sharing); and that did not have staff already trained in transitions protocols (primarily the Coleman care transitions intervention), which for some proved more costly to implement than anticipated. These and other start-up structural difficulties caused many CBOs to lose momentum, and many were not continued after the initial period.

Nevertheless, 44 CBOs continued to be funded and to operate through 2015. Those that did devised strategies for delivering comprehensive services post-discharge in beneficiaries’ homes, including helping them obtain assistance with personal care and household tasks they could not manage. The official CMS evaluation conducted by Econometrica focused mainly on readmissions, rather than close analysis of the actual interventions and lessons learned by both participating CBOs and hospitals in collaborating to manage complex, high-risk beneficiaries. Information from beneficiaries on their experience with the program was not collected.

To gain additional insights from CBOs, the National Coalition on Care Coordination and the Center for Health and Social Care Integration surveyed the more successful CCTP sites in late 2018 and 2019. The focus of this survey was to elicit additional information from CBOs about the basic structure of their programs, the nature of the adaptations they made to partner with hospitals, and the challenges they struggled with most, along with observations about what they have been able to take forward. Many of these responses suggest that CCTP opened the door for CBOs to make key improvements to the way that health care and care transition services are coordinated and delivered. As a result, hospitals and CBOs gradually became more efficient at communicating critical information about patients; relationships between medical and CBO staff improved; and referral processes solidified over time.

These adaptations and quiet successes can be seen in the continuing work that CBOs are now pursuing. For example, several CBOs that participated in the CCTP are now involved in CMMI’s Accountable Health Communities demonstration. More broadly, there is a clear push to organize AAAs into larger networks, both within states and more recently across states, to better leverage contracts with large health care organizations. This work is one of the legacies of collaborative work that was launched by the CCTP program.

Within the confines of the five year CCTP demonstration, CCTP sites made solid gains in driving down readmission rates and in lowering Medicare spending. For example, CMS’ final evaluation found that the average Medicare Part A and Part B expenditures over all sites was $634 or 8.23 percent lower in the 30 days after discharge for participants relative to matched comparisons. In the process of learning how to collaborate closely with hospitals on care transitions, CBOs developed better clinical protocols and increased their field capacity, thereby gaining experience in taking on contracts and acquiring valuable insights about how to market their services. The growing sophistication of the Aging Network is evident in the ongoing work of the National Association of Area Agencies on Aging’s Aging and Disability Business Institute. As more and more health care organizations look for ways to better control the costs of complex, aging Medicare and Medicaid beneficiaries, prospects for CBOs that can position themselves as nimble, flexible, business-savvy partners are excellent. As the Medicare population steadily increases in size and as the “longevity wave” takes hold, CBOs are in a prime position to expand their services footprint exponentially.

For a detailed overview of CBO experience with the CCTP as reported by participating sites, please click here to access the survey responses. Two of the interesting summaries from the overview are presented here:

The Four Overarching Themes from the Participant Surveys

CCTP Survey Responses Table

Community-based Health Organizations – An Innovation Path for Supportive Services

Posted by Greg Becker on June 18, 2019 No Responses » Tagged with: CMS, community-based, MediCaring book, MediCaring Communities, PACE, QIO

Jun 182019

Anne Montgomery
By Anne Montgomery

Time is growing short to make big changes to basic processes for service delivery to elders, who will soon constitute one-fifth of the U.S. population. Basically, we have a mismatch between the health care delivery system and what many older adults actually need.

Typically, older adults typically see multiple clinicians working in many settings – e.g., primary and specialty care, hospital care and home care — and communication between these providers tends to be inadequate. This in turn contributes to fragmented care that can be frustrating and costly. Medical services are often disconnected from the life goals and treatment preferences of a given individual, and his or her need for various supportive services are often not documented. Finally, although numerous smaller-scale initiatives have shown that much of the disability and frailty associated with aging can be effectively managed (and sometimes delayed or prevented), innovative models that prioritize these goals have not yet been widely implemented.

This suggests it’s a good moment for policymakers to consider piloting designated entities, perhaps called community-based health organizations (CBHOs), in order to organize provision of cost-effective supports across a population of high-risk, high-cost elders living in a given area or region. Broadly similar to a model developed by Joanne Lynn, MediCaring Communities, [https://medicaring.org/book-online/] CBHOs, operating as an interconnecting network, could be chartered to prevent and delay more costly inpatient and institutional care, working in partnership with local medical care providers. They would likely begin at a modest scale, forming networks in order to further develop business acumen, acquire information technology that is essential for interoperability, and develop collaborative relationships and contractual arrangements that over time can transition into more formal integrated care systems. As a distinguishing characteristic, CBHOs could measure and reinvest savings in improving community care systems.

Shifting the Entry Point Average Cost/Day [Click to enlarge]

One intriguing graphic, created by Preferred Population Health Management and reprinted here with permission, provides an illustration in one community of how delivery system entry points and costs might be re-thought. For vulnerable populations, which includes many older adults, it may make sense to consider looking at community-based organizations (CBOs) or Area Agencies on Aging (AAAs), as another entry point to a more tightly coordinated care system that prioritizes cost-effective services that reduce the risk of needing higher-cost interventions.

Changing the Entry Point to Health [Click to enlarge]

Using grant funding, CBHOs could be charged with standing up coordinated, synergistic delivery systems for older adults and individuals with disabilities across a service area. Collaborations could take various forms: partnerships between AAAs/CBOs and PACE organizations; with Federally Qualified Health Centers (FQHCs); with Rural Health Clinics (RHCs), and other possible combinations. CBHOs would be tasked with analyzing available data on the needs of all older adults and individuals with disabilities who live in the area, filling in with more complete data over time. They would then create a five-year plan for serving older adults in the area, with approval requiring consultation and sign-off by a local coalition representing providers, advocates, and individuals currently needing (and/or anticipating needing) services. Approved grant funding would flow to CBHOs, and states would be asked to assist in tracking CBHOs and their performance vis-à-vis standardized metrics, costs, and outcomes for individuals. At the expiration of the grant period, the federal government, in consultation with states and community stakeholders, would determine which CBHOs could become permanent.

There are several indications that policymakers are starting to consider such approaches. For example, a Senate draft of the Older Americans Act reauthorization, which is now circulating for comment, includes language stipulating that future OAA demonstration projects must address determinants of health; reduce health care expenditures, “preserve or enhance” quality of care to individuals, and prioritize initiatives that focus on caregiver support, multigenerational engagement and community-based partnerships.

There are other hopeful signs in work that is being led by the Center for Medicare and Medicaid Innovation (CMMI), which is teeing up a range of possible alternative payment models, and adaptations of existing programs to recognize and address social determinants of health in vulnerable populations. For example, as noted in our blog last month, [https://medicaring.org/2019/05/08/2019-cmmi-proposals/] CMMI has announced two groups of models, called Primary Care First and Direct Contracting. As part of the Direct Contracting Model track, CMMI published a Request for Information on how geographic contracting could work. Because they are typically limited to services that are available locally, older adults living with serious chronic illnesses and functional limitations and younger people with disabilities are populations that would be well-suited for a geographically-organized care model.

If local governments were allowed to be contractors, this could open up new opportunities for the Aging Network. To date, nearly all major federal innovation efforts have been geared toward large organizations working within the medical care system, but this could change. About half of AAAs are embedded in local governments, and AAAs and CBOs already understand how supportive services for older adults and other vulnerable populations can be efficiently delivered in very different types of communities. Moreover, as the nation’s primary publicly-funded network of community-based supportive services providers, staff are trained to organize and provide services in the home, and are therefore attuned to the life circumstances of individual elders.

In another encouraging development, CMS published an updated Scope of Work (SOW) in March for organizations applying to be Quality Improvement Organizations/Quality Innovation Networks (QIOs/QINs). Notably, this SOW instructs applicants to “coordinate with existing community-based efforts and reach community stakeholders to form community coalitions…[that] include the recruitment and engagement of providers across all care settings” — including those delivering community-based supportive services. QIN-QIOs will be required to use “a population based measurement strategy to show targeted improvement of beneficiaries that reside within specified ZIP codes” and to reach at least 414 community coalitions across the country. This means that QINs/QIOs will be actively supporting organizing of community stakeholders (providers, beneficiaries, caregivers and their families, emergency responders and more) in order to gather data that aims to improve care transitions and achieve specific reduction targets in high-cost inpatient hospital utilization.

By 2035, there will be 80 million older adults 65+ in the U.S., and the population age 85 and older will reach 12 million. And since many older adults have complex social needs and about one-third are living with a disability, this is an important time to try to shift the pattern of services further toward provision of home-based medical care and a more organized system of supportive, flexible, community-anchored services.

If we do too little now to deliberately boost the ability of the supportive services sector to innovate, it seems likely that unmet need for basic supports among many community-dwelling elders in the large boomer cohort will skyrocket. If this happens, health care costs will likely balloon. To help forward-thinking pioneers in this sector move forward faster, let’s hope that policymakers will give a green light to spurring development of collaborative, population-based care systems that are mission-driven to keep older adults at home and out of medical crisis for as long as possible. It’s a doable challenge, and the potential societal return on investment is large.

What Local Government Can Do for Aging Populations: Insights from San Diego County

Posted by Greg Becker on December 3, 2018 No Responses » Tagged with: aging, community-based, eldercare, MediCaring, public policy

Dec 032018

Authors Nick & Joanne
By Nick Macchione and Joanne Lynn

This blog entry was written for the Milbank Memorial Fund and is reposted here with permission.

State and local leaders who aim to improve population health must help older Americans live well with the challenges associated with aging. Given the rapidly rising number of elders, local governments have remarkable opportunities to facilitate improvements in health and quality of life for elderly people living with disabilities and serious illnesses. In March 2016, the county of San Diego joined both the AARP Network of Age-Friendly Communities and the Dementia Friendly America network to create the Age Well San Diego initiative. Age Well San Diego expands on the foundation of the County’s Live Well San Diego vision of a region that is “Building Better Health, Living Safely, and Thriving,” which was first established in 2010.

Age Well San Diego is a five-year collaborative process of assessing needs and working with community partners to develop, implement, and evaluate an action plan. With support from the San Diego Foundation and AARP, the county’s Health and Human Services Agency first held an Aging Summit to introduce the concepts of age-friendly and dementia-friendly communities. Additionally, the county held listening sessions to garner feedback from the public and arranged targeted focus groups to gain input from racial, ethnic, and linguistic communities, which often are not well represented. The planning sessions included a broad array of county departments. Live Well San Diego has long recognized partners, community groups, and other health-related organizations. The variety of input led to a comprehensive “Age Well San Diego Action Plan” that was approved by the County Board of Supervisors in May 2018.

The Age Well San Diego Action Plan identifies five priority themes: health and community support, housing, social participation, transportation, and being dementia-friendly. Goals, action steps, timelines, and metrics to measure success have been developed for each theme, and dementia-friendly strategies are woven through the other four areas. During the next three years, the county will work with community partners, interested stakeholders, and older adults to implement the plan, coming together to build age-friendly, dementia-friendly communities that will benefit residents of all ages. The county will continue to work closely with community partners, government officials, professionals and older adults to build a brighter future for people of all ages.

Guided in part by this Action Plan, San Diego County is making major strides in aging well. For example, the county has one of the lowest rates of hospitalization of elderly people in the nation, a health information exchange that includes data from county services, and much of the county’s public education system has focused on preventing falls, the dangers of inactivity, and hypertension. With the focus on older adults, and an added emphasis on those with Alzheimer’s and dementia, the county is creating an environment in which the elderly are better supported with wrap-around services, thus bolstering and strengthening their ability to remain in their homes and communities throughout their lifespan. Moreover, Age Well initiatives help older residents avoid preventable illnesses, stay engaged in their local communities, and obtain adequate support in the last phase of life.

Despite progress, the county still faces a substantial set of challenges in ensuring supportive care for people living with the disabilities associated with aging. Scores of supportive service organizations serve elders, but their capacities and eligibility requirements vary or change and are not coordinated. Medical care systems are mostly local, and they have cooperated on projects to improve emergency preparedness and care transitions. Most of the MediCal managed care plans, however, are owned outside of the county and are not yet well-connected with local services. Elders and their caregivers are too often left frustrated and anxious, and too many must cope with living without essential services. The county is exploring how to monitor how well elders are doing, both when they are still robust and when they are living with serious illnesses and worsening disabilities. While addressing these ongoing challenges, San Diego County remains an example to others looking at what local governments can do for aging populations.

The Aging Well planning process makes it clear: if a health care financing and service delivery system were designed now for elderly people who might live for years with serious chronic conditions and disabilities, it would not be based on traditional fee-for-service Medicare. Instead, it would prioritize ensuring that adequate food, shelter, personal hygiene, eyeglasses, hearing aids, foot and dental care were all available. The affected population and their families would be involved in deciding which medical services help people live well and need to be readily available, and which services have little impact, given a patient’s age and condition, and need not be readily available. For people who can’t leave their homes, services need to come to them, with appropriately prompt response times.

Optimal policies must go beyond standard preventive health care services and medical care delivery to involve social determinants of health, including education, living or working conditions, and societal connectedness. The built environment, the local workforce, and the services available shape the experience of elders and their families in profound ways. Adapted housing and transportation for the elderly, for example, enable community living, while shortages push elders into nursing homes. When the elderly have access to parks and community spaces, they are more likely to get physical activity and engage with others, reducing isolation and depression.

These ideas are coming together in the MediCaring® Communities reform proposal. The MediCaring® Communities concept proposes additional reforms, including capturing funds saved from avoiding wasted and low-value medical care and instead investing them in community-based services. Currently, health insurance ensures that a frail elderly person can get any costly drug or surgery, but that same person often faces challenges in finding shelter, personal help with bathing, or dental care because these essential services have inadequate funding.

San Diego’s social services and its health care providers have long been committed to enhancing the health of its people, as demonstrated by Age Well San Diego and other collaborative and innovative endeavors. However, the county’s ability to test more fundamental reforms is constrained by established processes and financing. Creating a set of reliable and efficient social arrangements to support a large and rapidly growing number of frail and disabled elderly people will require the opportunity to test substantial innovations. The MediCaring® Communities model provides such an opportunity.

The Center for Medicare & Medicaid Innovation within the Centers for Medicare & Medicaid Services should enable a few communities, like San Diego, to work intensely with their elderly population to demonstrate how a highly reliable and efficient aging care system could be developed for the elders who must live with disabilities and illnesses. Funding should aim to stay within current aggregate costs to elders, families, communities, states, and the federal government, but some funds would be directed to reforms that benefit all elders and their families—such as workforce training, caregiver support, dental care, and so forth. Many communities likely would join and build this future—just in time for the aging of America.

Nick Macchione serves as San Diego County’s director of the Health and Human Services Agency, which serves over 1.3 million people. He is also the architect and strategist of “Live Well San Diego.” He is a fellow of the American College of Healthcare Executives, a Public Health Leadership Scholar with the Public Health Institute/Federal CDC, and a Creating Healthier Communities Fellow of the American Hospital Association. Macchione holds master’s degrees from Columbia University and NYU specializing in leadership, management, and policy. He serves vice chair of the Milbank Memorial Funds’ Reforming States Group.

Read Joanne Lynn‘s biography.

What We Know to Do Won’t Be Done and Wouldn’t be Enough! (But We Could Make Eldercare Work!)

Posted by Greg Becker on October 18, 2018 No Responses » Tagged with: caregiving, community-based, frail elders, Joanne Lynn, MediCaring Communities

Oct 182018

Dr. Joanne Lynn, MD
by Joanne Lynn

Our aging society is a mountain to be moved – a large collective challenge we have to tackle together. Problem is, right now we’re using shovels when bulldozers would hardly do the job.

The mountain is reforming how eldercare is delivered and funded. We’ve allowed so many forces to converge over the years in a payment-driven, provider-centric framework, that we’ve managed to create a grim future for the last phase of aging. Most of us will have at least a couple years of self-care disability in the last years of life, no matter how healthy our life styles may become. While “healthy aging” is a terrific idea, it is one that eventually fails in most lives, simply because some form of frailty will still disable us, for a long time, and presage death.

Families are smaller, older, and more dispersed – there is often simply no one able to provide free care at home. Retirees have ever lower savings and insurance, overwhelmingly too little to pay for an expectable range of personal care. Medicaid is stretching state budgets and many more are set to spend down to eligibility. Communities have no entity actively monitoring and managing the performance of their unplanned and poorly coordinated eldercare arrangements. Serious illnesses and disability in old age is the dominant cause of family impoverishment and bankruptcy. Paying current per capita costs by raising taxes is not plausible by the mid-2030s [National Research Council. 2012. Aging and the Macroeconomy: Long-Term Implications of an Older Population. Washington, DC: The National Academies Press. https://doi.org/10.17226/13465] – we will find ourselves balancing crippling the economy with abandoning dependent patients. Being able to support an expansion of public services and supports to accommodate more elders in need depends upon a thriving economy, and that depends upon highly productive young adults. Yet we now have half of children born into poverty and we tolerate high rates of young adults being unprepared for productive work.

Many issues compete for our attention. Why bother with dealing with old people? Two pragmatic reasons: old people and their children vote, a fact that makes it unlikely that elder care issues will be abandoned; and all of us will eventually join that cohort, a fact that makes it everyone’s issue. Furthermore, we really are part of a community, and we really won’t be able to ignore a retired school teacher’s homelessness, the gnawing hunger and painful isolation of a former jazz musician. Our better natures will require making basic needs available on a reliable basis.

In 2016, our team at Altarum worked with other national partners to push for caregiver planks in state and national party platforms — 11 states included a plank as well as having the issues show up for the first time in both Democratic and Republican national platforms. [Scribner, B. et al. (2017). Creating A Nationwide Nonpartisan Initiative for Family Caregivers in Political Party Platforms. J Am Geriatr Soc, 65: 1126-1131. doi:10.1111/jgs.14814] A key finding of voter polling work in this project was that voters of all political persuasions are energized and passionate equally about the needs of caregivers and supports that ought to be made available to families.

But how? The costs look to be overwhelming. The effects upon the economy and the opportunities for younger persons look to be disastrous. It is so much easier to duck and run – answer to the immediate issue but make no fundamental changes. There’s a better way.
Our arrangements for medical care assumed that people are mostly healthy and on their own, and from time to time they need medical care to return them to health. In frail old age, the question is not mostly to “fix it” but to “live well with it.” In this setting, continuity, care planning, and caregiver support matter – three elements that are mostly missing in our current health care. We need to dramatically reorganize health care to require these elements as essential in elder care.

What happens to support frail elders depends critically upon the arrangements for support in their geographic community. Is disability-adapted housing available and affordable? Can you get appealing and affordable home-delivered food? Is there an adequate workforce skilled in handling personal care at home, even for persons with dementia and persons who are difficult to serve? Do the dominant employers provide flexibility for family and volunteer caregivers? Are there volunteers organized to fill in most “instrumental activities of daily living,” such as minor home repairs and delivering food? Perhaps most important, is there an entity with the responsibility to address these issues – to monitor performance in that community and take steps to improve it?

With many communities doing this, communities would be able to benchmark performance and manage the arrangements in their community. Lots of independent businesses would still thrive, but collective action would also be possible and practices that distort service availability or quality could be constrained. Altarum developed a Financial Forecasting Tool [https://medicaring.org/2018/07/24/mcforecasting/] that can help communities understand the resources they already have — medical and health services, social services, community volunteer organizations, and others — and quantify the possible savings a reformed system of eldercare can produce. There is a lot of money being spent in the period when elderly persons live with serious disabilities, but it is not being used in planned, efficient, person-centered ways.

This is a more fundamental reform than just moving medical care to the home or providing coordinated post-hospital care, or whatever combination of currently “evidence-based” improvements you prefer. This is making some part of elder care into a public concern, managed at the community level. It is not just for dual-eligible elders, it is not just for persons who run up high bills, and it is not just for persons with particular diagnoses. This reform is for us all. We’ve called it MediCaring Communities. [https://medicaring.org/book-online/]

We must work on financing and service delivery at the same time. If we started now to build private savings for long-term care (through savings accounts or insurance), we’d have capital to stimulate the economy as well as less demand for public funding in fifteen years. Having a federal back-stop on long term care costs would create a vibrant marketplace for long-term care insurance. Professionalizing assistance with personal and supportive care would create better paying jobs in the care sector and these professional caregivers would be able to build a new middle class around eldercare professions, thus boosting, rather than draining, local tax bases. Planning for the whole populace also requires substantial reinvestment in ensuring that our children come into adulthood as highly productive citizens.

This is our opportunity time. If we buckle down and enable substantial innovation in some counties and cities, we’d learn what’s possible and other counties and cities would follow suit. We urgently need an era of profound and far-reaching innovation and learning. What can you do make it possible to overthrow the status quo? Be in touch with one another and with us – let’s dramatically increase the pace of improvement and build an elder care system that is highly reliable and efficient and build it in time to accommodate the rising numbers of disabled and frail elders.

Pick up the PACE to a New World of Eldercare

Posted by Greg Becker on August 21, 2018 1 Response » Tagged with: CMS, community-based, eldercare, frail elders, PACE, public policy

Aug 212018

Christine Stanik
By Anne Montgomery, Sarah Slocum and Christine Stanik

What do you need to know in order to remain in your own home as the years advance? Where can you turn for good, reliable services in a costly, chaotic, constantly shifting health care system? One possible answer is PACE (the Program of All-inclusive Care for the Elderly) program. PACE is widely acknowledged to be the “gold standard” of comprehensive geriatric care – which is not just medical care, but also long-term services and supports (LTSS).

But PACE is not yet available in 19 states, and currently has limited capacity, serving about 45,000 beneficiaries (almost entirely elderly persons who are enrolled in both Medicare and Medicaid). Beyond the dually-eligible population, how can we expand PACE to a burgeoning population of Medicare-only beneficiaries, many of whom need some LTSS, and who would very much like to avoid spending down to Medicaid level?

Medicare Advantage

One area of likely growth for PACE is to partner with Medicare Advantage (MA) managed care plans. Recently, the Centers for Medicare and Medicaid Services (CMS) published guidance allowing MA plans to expand the range of supplemental benefits they may wish to offer to include a range of LTSS. MA plans could contract with PACE (or another service organization), to furnish PACE Center attendance and transportation to and from home; meals; and other services to help enrollees avoid hospitalization, emergency department visits, and maintain stability even during periods of decline. For working family caregivers, PACE can be a huge help, serving as a source of reliable respite. And increasingly, evidence is accumulating that such arrangements can reduce in-patient hospitalization and ED costs, and delay or prevent long-stay placement in nursing homes.

To serve current community needs and prepare for larger offerings through MA contracting, some PACE organizations provide services to non-PACE enrollees as a private pay offering. PACE plans have varying levels of experience providing a la carte or service packages to non-PACE enrollees. At the Program to Improve Eldercare, we are developing policy pathways and practical tools to help PACE organizations and MA plans prepare to work together to better serve frail elders. First we need to address the daunting Part D affordability barrier that faces Medicare beneficiaries wishing to enroll in PACE that Sonja Love Felton described in a previous blog. Fortunately, CMS is aware of the problem, and may be open to a system-wide solution. We invite you to encourage them (contact us for guidance at [email protected]).

Medicaid

Another set of challenges to accessing PACE for some Medicare beneficiaries is that they lack the personal resources to pay out of pocket for LTSS. Many in this group have just slightly more income than their state’s Medicaid income eligibility threshold permits. If their monthly medical expenses are high, and this can be documented, some of these beneficiaries can take advantage of the so-called “medically needy spend down” option 33 states have. However, in most states, this option requires a large monthly deductible leaving only small amount of income (as low as $400 per month in some states) to pay for all living expenses. The rest face the “Medicaid cliff” –with an absolute cut off level, usually 300% of the SSI limit, which is $2250 in 2018 and cannot qualify for Medicaid if they are one dollar over the limit. The predictable result is that many families wind up impoverishing themselves to gain access to LTSS – which may only be available in the highest-cost setting – a nursing home. To solve these dilemmas, the Program to Improve Eldercare is working with Medicaid experts to identify practical, workable policy solutions that can be readily implemented, and which can make PACE LTSS services available to many more Medicare beneficiaries. States will ultimately save Medicaid dollars and avoid premature nursing home placement by allowing people to avail themselves instead of lower cost PACE services.

In the course of analyzing these challenges, we have been speaking with Michigan families who generously agreed to tell us their stories. Michigan is a state with an absolute cut-off for Medicaid – if your income is more than $2250 per month, you cannot qualify, even if your medical costs and personal care needs alone are $3000 per month. We relied on family caregivers to speak for elders they are supporting. They provided us insights into what happens to families who find PACE attractive, but who do not qualify for Medicaid and do not think they can afford to pay for long-term services and supports (LTSS) out of pocket. To protect the privacy of those interviewed, we have changed the names below, and details from several individuals are combined in the two composite narratives.

Tom’s Story

We spoke with Tom less than six months after he had contacted PACE on behalf of his octogenarian mother. Because she was becoming increasingly frail and unable to live on her own, Tom moved his mother into his own home. Not yet at retirement age, he soon realized that the demands of caring for her were at odds with a job that kept him away from home for up to 10 hours a day. Tom called PACE to express concern for his mother’s safety when she was home alone, noting that her physical condition was likely to degenerate over time due to several worsening health conditions.

Although Tom and the PACE program concurred that enrolling his mother would be the right solution to an otherwise hazardous situation, the cost of PACE, more than $4000 per month, put it beyond their reach. This left Tom to piece together services as best he could. However, eventually his mother had a fall when he was away from home, breaking her hip. At the time of the follow-up interview, she was convalescing in a nursing home, and Tom was desperately trying to find a better alternative. He was deeply concerned that a lack of adequate rehabilitation at the facility was preventing his mother from regaining her mobility. Although he did not have a plan to keep her safe if she returned home, Tom was exploring options to try to bring his mother home and also obtain therapy that could help her regain strength and the ability to walk. Overall, from a family caregiver’s perspective, the options presented had gone from hazardous to punishing – reliable, ongoing supportive services in a safe environment that would have made both of their lives much better were simply unavailable, because they fell between having a bit too much income for Medicaid, but not enough to pay for PACE.

Sheila’s Story

We spoke with Sheila a couple of months after she had contacted PACE on behalf of her elderly father. After the death of her mother, Sheila became concerned about her father’s social isolation and depression. Declines in physical health and the beginning signs of cognitive impairment were limiting his ability to venture out on his own to see friends and attend medical appointments. Sheila believed the PACE program would be ideal for her father, given that the PACE Center could provide an easy way to access the social interaction he sorely needed, and his medical care would be managed and monitored, alleviating worries about making and tracking various appointments for medical services that created burdens both for him and for her.

Unfortunately, her father’s small pension made Sheila’s father ineligible for Medicaid — without providing enough money to pay the out-of-pocket monthly PACE fee. Given the difficulty of caring for her father’s health needs, and growing concern for his acute loneliness, Shelia made the decision to buy a larger home that would allow her father to live with her family. Unfortunately, this did not work out as well as she had hoped, in part because she and her husband had full-time jobs, and had difficulties transporting her father to various medical appointments that were always scheduled during business hours.

Sheila was also concerned about her father spending most of his days alone. He still drove his own car, but was starting to show signs of forgetting even the most familiar of routes, and she suspected he would soon be unable to drive at all. Sheila was highly motivated to do all she could to help her father maintain a good quality of life in his final years and reported that the PACE Center continued to be the most attractive option for both medical services management and for social interaction. At the time of our last call, she had begun looking into the feasibility of having her father’s pension reduced in order to try to qualify him for Medicaid, so she could enroll him in PACE.

Reflections and Next Steps

Tom and Sheila were both doing their best to care for parents who had reached advanced old age. Both parents worked all of their adult lives and had accumulated some resources for retirement, and the comprehensive care model of PACE was a terrific solution for addressing several concerns. PACE was by far the option – but under current rules, it was beyond their financial means, and no other set of services was adequate or available.

These stories show why we are working on advancing flexibility in PACE, both in Medicare and Medicaid. PACE is well-positioned to serve many more people in a long-lived society if we can get policymakers to agree to implement commonsense solutions that remove current barriers. We hope you will join us in the endeavor, and if you want more information about PACE innovations, please contact us at [email protected].

Financial Forecasting for MediCaring Communities

Posted by Greg Becker on July 24, 2018 No Responses » Tagged with: best practices, community-based, MediCaring Communities

Jul 242018

Anne Montgomery
By Anne Montgomery

Imagine a meeting in your community — perhaps later this fall or next year — where you assemble a group of like-minded peers: health care providers, organizations offering supportive services, advocates, local leaders, policymakers and other interested stakeholders. You are calling them together because they all have an interest in improving the health and well-being of older adults in the area. Now, further imagine that at this meeting, you are aiming to craft a strategy that will establish, using current programs, a more efficient system of service delivery that reduces spending — in a way that keeps any resulting savings in the community.

If this sounds like something you may want to consider, keep reading! Altarum’s Program to Improve Eldercare has created a financial simulation model that contains essential data, and which can be used to benchmark costs for creating community-anchored eldercare systems. We call this tool “Financial Forecasting for MediCaring Communities.”

Here’s how the tool works:

First you’ll need to know (or create a good estimate for) how many older adults live in the area and require a mix of calibrated services – usually including medical care and supportive services delivered at home. Then you need to examine the improvements that evidence shows are likely to keep them more stable and out of medical crisis more of the time. Next you need a willing group of providers in the area – inclusive of hospitals, physicians and supportive services providers – who are interested in creating a more coherent system for older adults who are living with advanced illnesses and functional limitations. Interested parties you may want to talk to include PACE organizations, Emergency Room clinicians, long-term care providers, Medicare Advantage plans that offer expanded supplemental benefits (which have recently been enabled to look at supportive services in the context of expanded supplemental benefits), home-based primary care programs, and other service arrangements.

Using the tool, you can construct baseline cost estimates for each major service category, from inpatient hospitalization through lab services, durable medical equipment, vision, dental, long-term services and supports (LTSS), and more – on a per-person basis. Then your team projects expected changes in spending over several years, which will come from shifting the mix of services to focus more on primary care, skilled home health care and supportive home care, as well as supportive services (e.g., home-delivered meals, adapted housing and transportation. Because a rapidly expanding body of evidence shows that when lower-cost geriatric care and supportive services are emphasized, utilization of costly inpatient hospitalization and long-stay nursing home placements decline, this then yield targets for reduced overall spending.

After that, the tool will calculate projected savings, taking into account projected enrollment targets. Next you estimate start-up and ongoing administrative costs to implement that changes and to cover an entity (possibly comprised of some of the individuals at your meeting) that will monitor and track how well providers in the area are doing in delivering cost-effective services to frail elders. That entity, which we’ll call an “eldercare council” will be sustained from the savings that the improvements generate, so your team will need a plan for capturing and using at least part of the savings in your community.

Intrigued? We invite you to click on this link and watch the 14-minute video demonstration — https://youtu.be/K8rKW48Felw -– and send us an email if you’d like us to help you create a simulation for your own community: [email protected]

Altarum Invites Communities to Apply for Eldercare Planning Contracts

Posted by Les Morgan on June 18, 2018 1 Response » Tagged with: care transitions, community-based, eldercare, information technology, measurement, quality improvement

Jun 182018

The Program to Improve Eldercare (PIE) at Altarum Institute is preparing to award several small contracts to healthcare organizations, Public Health Departments, Area Agencies on Aging, and community-based organizations (CBOs) to carry out guided planning efforts to improve care for frail elders though more effective use of existing data concerning persons living in their catchment areas. The overall goal is to help local management define and generate measures of the local system’s performance concerning eldercare.

The contracts will not require collecting any new data. Each site will work with their own data that is already on hand to conduct aggregated analyses for their own community and region. The results of all funded contracts will form the basis for a national White Paper on how communities across the United States can monitor and manage the arrangements for care for elders living with disabilities and chronic conditions through improved use of aggregated data from multiple sources, such as clinical care, surveys, and use of community services.

Our goal is to empower communities and therefore to fund pilot projects that show high promise using several different approaches to community management of eldercare. Throughout, we aim to work with the sites to identify and document business models in use at the partner sites to support existing or improved system performance for providing adequate supportive care services.

This effort is funded by the Gordon and Betty Moore Foundation through Grant GBMF5662 to Altarum Institute (“Aggregating Care Plans to Manage Supportive Care Services for Elders”), Joanne Lynn, M.D., Principal Investigator.

We invite organizations to contact us to discuss this in order to determine their interest in participating. Please contact us via email to [email protected]. We will be happy to help you determine if your community would be a suitable candidate for these projects.

Contracts will be awarded in two phases.

Site Readiness Assessment Contracts (Performed from July 2018 through November 2018)

Site Pilot Implementation Contracts (to be completed by June 2019)

Site Readiness Assessment Contracts (Performed from July 2018 through November 2018)

The Readiness Assessment contract phase will select up to ten geographically-focused organizations (“sites”) to receive a contract of $10,000 to participate in a structured strategic planning process to help the sites evaluate their current uses of data related to service provision for elders in their geographic region. We are looking for sites that at least begin to represent a geographic community’s population and that include at least some attention to both social supports and medical care. We are interested in entire catchment areas as a service delivery setting. With assistance from our national program staff, the sites will prepare a Readiness Assessment and strategic plan for improving quality and reducing cost for their eldercare system through better use of data and management information systems.

Our national staff will work with each of the sites to prepare a customized project plan that works backward from the seven strategic planning outputs we are studying for each site. The list of outputs in seven study domains is summarized in Appendix A, below. At the end of the planning process, each site will receive a Readiness Assessment report that will form the basis of our selection process for the next round of contracts, which will provide limited funding toward some costs of actual implementations in some sites.

Site Pilot Implementation Contracts (to be completed by June 2019)

This phase will award Pilot Implementation contracts at up to six sites to carry out pilot projects based on their Readiness Assessment results. The amount of the Pilot Implementation Contracts will vary depending on the projects proposed by the sites, but we expect that the minimum awards will be approximately $30,000 per site. Some sites may receive larger awards if their plans are complex. As with the Readiness Assessment contracts, our national staff will provide advisory assistance, but actual work will be done by the sites themselves to ensure that an ongoing capability is built locally in a sustainable manner. The Pilot Implementation contracts will probably not cover all implementation costs for every project. Local participation will be needed to ensure the pilot has some chance of being sustainable.

If, at the end of the Pilot Implementation, a site has built a working data flow environment and demonstration management information system and has shown that the analytics coming from it are of actionable value to decisionmakers, our national staff will explore with them ways to seek continuation funding to help them transition the pilot system to an ongoing management reporting system. Continuation funding is not guaranteed as part of this effort, so finding ways to create sustainable business models is an important part of the process.

How to apply to partner in this work

To apply, send Email to [email protected] AND [email protected] with the following information:

Subject line – “Community Eldercare Metrics, Planning”

State the contact email(s) and phone number(s) of the person or team applying.

Define the community you aim to serve.

Briefly explain your vision, governance, and data available to the project.

Send it soon! We will follow up with the more promising teams on a rolling basis and aim to have all teams identified within July 2018 and to have plans and contracts within August and September 2018, depending upon labor availability at the sites and in our staff.

Appendix A: Overview of Site Readiness Assessment Domains

The site Readiness Assessment planning process will provide sites with a $10,000 contract to work with our national staff to explore seven key domains that are essential to creation of an effective management reporting system for community eldercare. We do not expect that all sites will have advanced information technology capabilities in place. Information for this process is expected to be collected primarily by videoconferencing, with little or no travel expenditures for site personnel. The questions listed in this table will be explored during the Readiness Assessment contract period, and need not be answered as part of a contract application.

You may download a PDF file with details on the seven Site Readiness Assessment Domains.

You may download a PowerPoint presentation with further details on the process for Site Readiness Assessments and information on how to apply.

Expanding PACE Opportunities in Our Community

Posted by Greg Becker on May 17, 2018 No Responses » Tagged with: community-based, eldercare, MediCaring, PACE, public policy

May 172018

Sonja Love Felton
By Sonja Love Felton, LMSW, MPA
Executive Director of Huron Valley PACE
huronvalleypace.org

Huron Valley PACE, in Ypsilanti, Michigan, is a young PACE organization – we were established only 4 years ago. However, we’ve been moving quickly since the day we opened our doors. Most readers likely know that PACE is an acronym for Program of All-Inclusive Care for the Elderly, a tremendously innovative program that became federal law back in 1997. Today, we provide comprehensive, high-quality, person- and family-centered care, mostly to dually eligible beneficiaries 55 and older – but as the Executive Director of Huron Valley PACE, I can attest that we have larger ambitions.

Here’s how we plan to grow: In March, we broke ground on a new wing that will allow us to enroll an additional 120 participants next year. Today, we serve 162 participants. Beyond enrolling more dually eligible participants, we are tackling the challenge of identifying policy pathways and implementing changes that will allow us to expand to serve a Medicare-only population. With our country’s age wave steadily gathering momentum, we want to build our capacity to enroll seniors who are not Medicaid eligible – either because they do not require a nursing home level of care or because they are not financially eligible (less than $2,250 in gross monthly income and less than $2,000 in assets).

To do this work, we are partnering with Altarum in a project supported by a grant from the Michigan Health Endowment Fund to find innovative ways to expand availability and affordability of PACE services to more elders and people with disabilities in our local service area. In our work to date, we have identified a major barrier for enrollment of Medicare-only participants – the cost of prescription drug coverage. Here’s the dilemma: dually eligible participants have all of their Part D costs covered, but due to conflicting provisions in the original PACE statute and the 2003 law that established the Part D program, Medicare-only participants are now forced to pay exorbitantly high premiums for their drug coverage — $1099 per month in 2018 in our program. That compares to the average $45.15 for a local Part D Prescription Drug Plan (PDP).

To resolve the conflict – which arises because PACE prohibits payment of co-pays and deductibles, and the Part D law requires that co-pays and deductibles be paid to qualify for discounts during the “doughnut hole” coverage gap as well as for catastrophic coverage – Altarum and Huron Valley PACE crafted a PACE and Part D waiver that we have submitted to the Centers for Medicare and Medicaid Services (CMS). In developing a waiver package, we also worked with the actuarial firm Milliman, Inc., to develop a pricing strategy that would allow Medicare-only participants to pay us a premium that covers buying a market-based plan and also covers out-of-pocket copays, deductibles, and over-the-counter medications. The monthly amount would total about $320. We think this is a creative solution that would allow people to keep their Medicare Part D plan and remain enrolled in PACE. We are excited about having the support of the PACE Association of Michigan (PAM), the National PACE Association (NPA), and Representative Debbie Dingell for this waiver.

In 2011, CMS approved a similar waiver for Medicare-eligible veterans, so that they could receive their drug coverage from the VA’s very affordable, high-quality prescription drug coverage program. As of mid-May 2018, we are awaiting news from CMS about our ability to move forward and begin to offer this innovative, lower-cost prescription drug option.

Another exciting development in Michigan that will make PACE more available to frail older adults is a revision to Michigan’s Nursing Facility Transition (NFT) Program which will include PACE as an option for people moving out of nursing homes and back to the community. Much of the NFT work Michigan has done – and thousands of people have already been helped to move back to the community from a nursing home – has been under the federally enacted and funded Money Follows the Person (MFP) program. While the current version of the MFP program is expiring, federal policy makers and advocates are optimistic that a new version of MFP will be forthcoming. Including PACE as an option for people who want to move from nursing homes back to the community will provide a more complete and choice-based set of options for our elders and people with disabilities.

Finally, for people who would be served well in PACE but have a bit too much income to qualify for Medicaid, Huron Valley PACE and Altarum are working with national and state level experts on Medicaid policy to develop a pathway that would enable the participant and Medicaid to share in the costs. Currently, these individuals eventually have to use a nursing home, almost all of their income is paid to the nursing home, and Medicaid picks up the rest. The cost to Medicaid would be lower in PACE and the elderly person would keep living in his or her home much longer.

PACE has been successful in providing comprehensive, coordinated, customized, high quality social and medical care to some of our most vulnerable citizens. Huron Valley PACE is pleased to be a part of this work with Altarum to explore groundbreaking ways to make PACE more available and affordable for a broader array of people who need such support and care in our community. Once we blaze the trail, many other states and PACE programs can make PACE much more broadly available.

For information concerning PACE at the national level, visit the National PACE Association website

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