Aging in place is the ultimate goal, but the list of support and services necessary to do so grows longer every year and is both generic to the process and specific to each individual.
A strategic partnership between Aging & In-Home Services of Northeast Indiana (AIHS) and Parkview Health combines the best clinical and social care in the region to provide seniors in Allen County with a new solution to the challenges of aging in place: PACE of Northeast Indiana.
“PACE stands for Programs of All-Inclusive Care for the Elderly,” says AIHS President and CEO Connie Benton Wolfe. “This unique model of integrated care combines clinical and social care under the same roof, which has proven to extend individuals’ ability to successfully live in the community.”
PACE® began in 1971 in San Francisco to address the ongoing needs of seniors who needed nursing home-level care, but wished to remain at home with loved ones. The program quickly became popular among seniors and family caregivers alike and was awarded Medicare and Medicaid waivers to operate. PACE® is now a permanent provider under both the Medicare and Medicaid programs.
“This partnership with AIHS is an extension of the services Parkview already provides,” says Parkview Chief Clinical Integration Officer Dr. Greg Johnson. “Parkview is committed to making health care accessible to those who need it and we are grateful for the opportunity to address health where it happens – in the home.”
Chronic conditions such as diabetes, high blood pressure and COPD can limit a person’s ability to maintain an independent lifestyle. On average, PACE Participants have been diagnosed with five or more chronic conditions that interfere with essential activities, such as bathing, dressing and preparing meals. Poorly managed chronic conditions, combined with low quality of life from unmet basic needs, can have severe effects on an individual’s overall health.
Older adults are often faced with a number of social issues, or social determinants of health (SDOH), that impact their health and overall quality of life. Addressing these social issues, alongside others addressed by clinicians, provides access to the hands-on care required to support this vulnerable population.
“The care provided by PACE is like no other,” says Nursing and Quality Supervisor Pam Quaintance. “When you become a PACE Participant our team performs multiple assessments, both in your home and at the PACE Center, to determine the best approach to keep you healthy, safe and living independently.”
At PACE, care is managed by an Interdisciplinary Team (IDTeam). This team is comprised of 11 clinical and social disciplines including professionals in primary care, occupational and physical therapies, activities, social work, home health, nutrition and transportation.
“Transportation is a major social barrier for older adults,” says Vice President of PACE operations Katie Hougham. “When meeting with a potential Participant and their caregivers, the benefit of included transportation draws a sigh of relief knowing their loved one has a ride to and from appointments.”
The IDTeam prepares individualized care plans for each Participant and meets regularly to discuss each Participant. This process ensures that whatever the Participant’s need, the entire IDTeam is aware and can address it together.
The reason PACE programs call its clients “Participants” supports the philosophy that each client is active or, participates, in their care. Participants set goals, approve care plans and work alongside the IDTeam to improve their health.
“We opened our doors to Participants on July 1, 2021 and we’ve already been able to celebrate their success,” says Hougham. “One of our first Participants set a goal to be able to walk into an upcoming appointment without use of their wheelchair. Within six weeks of regular therapy they were able to do so for the first time in over 12 months.”
PACE is not only a day center and a clinic; it is also a Participant’s insurance provider. In addition to the care Participants receive, they also receive their medical equipment and prescriptions from PACE. Because PACE is a provider under both the Medicare and Medicaid programs, the PACE benefit is typically available to dually-eligible individuals at no cost.
PACE staff is available 24/7 to address ongoing and changing needs. PACE is a partner in the Participants’ health and the staff wants to know what is happening in real time to address their needs.
“A non-life-threatening event such as a sudden illness can be addressed by our on-call staff,” says Quaintance. “Having staff available at all times keeps our Participants out of emergency departments when possible. The PACE benefit allows us to send a nurse to their home to assess the situation and provide care.”
“PACE® is an extraordinary model nationwide,” says Benton Wolfe. “What makes PACE of Northeast Indiana unique is we have been able to blend the social care expertise of AIHS with the clinical excellence of Parkview into a transformative web of care that best serves the complex needs of our vulnerable community-dwelling individuals.”
To become a Participant at PACE of Northeast Indiana you must be 55 years of age or older, live in Allen County, qualify for nursing home level of care and be able to live safely in the community with the support provided through PACE.
The enrollment process includes four steps: an in-home visit, a visit to the PACE Center, the creation of the individualized care plan and the approval of that plan by the potential Participant and caregiver, and from the IDTeam.
The PACE benefit offers rolling enrollment, meaning enrollment can occur at any time throughout the year. For individuals who already have the Medicare and Medicaid benefit, the PACE enrollment process typically takes 30-45 days. If an individual isn’t enrolled in either of those benefits, PACE can assist in determining eligibility and help with enrollment. Once a potential Participant is approved for care, the PACE benefit begins on the first of the month following approvals.
PACE of Northeast Indiana joins four other PACE Programs in Indiana and over 140 across the United States.
To learn more about PACE of Northeast Indiana, visit: pacenein.org.
