THE VIRGINIAN-PILOT
Copyright (c) 1995, Landmark Communications, Inc.
DATE: Monday, February 27, 1995 TAG: 9502270062
SECTION: LOCAL PAGE: B1 EDITION: FINAL
SOURCE: BY DEBRA GORDON, STAFF WRITER
LENGTH: Long : 239 lines
When her aunt broke her hip for the third time, everyone - from the doctor to the social worker - told Carol Cooper to put the 80-year-old woman into a nursing home.
But Cooper insisted that Florrie Ross, whom she calls Big Mama, stay in the white-columned, brick home in Columbia, S.C., where the older woman had lived for more than half a century.
Luckily, an innovative program designed to keep frail elderly out of nursing homes and hospitals had just begun in Columbia. Called Palmetto SeniorCare, it was modeled on the 20-year-old On Lok center for elderly residents of San Francisco's Chinatown.
And they had a spot for Ross.
Five years later, Big Mama still lives at home, cracks jokes with her niece, whom she fondly calls ``baby girl,'' and spends five days a week at the adult day health center that is the heart of this project.
Now, Sentara Life Care wants to bring the On Lok model, called PACE (Program of All-Inclusive Care for the Elderly), to Hampton Roads. Sentara is awaiting state and federal approval for the program.
Sentara hopes to open its first center in Virginia Beach this summer, in an urgent care center that could accommodate 120 to 150 participants. Eventually, it plans to replicate the program in Portsmouth and on the Peninsula, serving up to 600 elder ly adults in four sites.
Start-up costs are estimated at $1.5 million, which Sentara's parent company, Sentara Health System, is funding.
If it is successful, Sentara will be providing a rare alternative for people who need the skilled care of nursing homes and a much-needed respite, as well as peace of mind, for their caregivers.
It also may provide substantial savings for the state, which, in 1993, spent nearly $350 million on nursing home care for 24,500 elderly Virginians under Medicaid.
``It's an excellent program, the wave of the future,'' said Joe Teefey, deputy director of the Virginia Department of Medical Assistance Services, which administers Medicaid. ``It controls the institutionalization of people by keeping them in the community, in their homes, and getting them the proper medical care and attention they need to stay there.''
Viola Benefield sits in her wheelchair in the treatment room at the Shandon Day Health Center in Columbia, staring at her bare left foot.
Benefield, 74, already has lost one leg to diabetes. The sores and broken skin on her foot worry the staff.
Because they routinely check all diabetics for foot problems, chances are they've caught this outbreak early. That means they can treat it here, in the six-bed treatment room, at a fraction of the cost that would be required if Benefield had to be hospitalized or have her leg amputated.
It's just one way the PACE model differs from other programs for the elderly.
Unlike an adult day care center, in which participants congregate in a community center where they eat and socialize, PACE sites brings acute and preventive medical care into the center.
Unlike a nursing home, in which physician visits and preventive, holistic health care are rare, PACE centers have physicians, nurses and therapists on site every day.
But, like a nursing home, PACE participants are frail, and must meet their state's eligibility criteria for nursing home admission.
That means Palmetto, whose home of South Carolina has one of the country's most stringent requirements for nursing home care, has one of the most frail PACE populations.
Its participants, most of them indigent, come to the program's three sites with an average of six chronic illnesses, taking an average of eight to 10 medications.
``When you get most of your care from a doc-in-the-box or the emergency room, it costs a lot to the system and it's not well-managed,'' said Palmetto Director Judy Baskins. ``We spend the first three months here just tuning them up.''
And yet, of Palmetto's 215 participants, only 14, about 6 percent, are in a nursing home, duplicating PACE statistics nationwide.
Palmetto's participants average about 3.4 days in the hospital each year, less than half the average hospitalization rate for all Americans over 65, said Baskins.
And the program saves money - spending only about 71 percent of the dollars Medicare and Medicaid would have spent on these recipients, Baskins said.
When they join the program, members sign over their Medicaid and Medicare policies. Palmetto then receives $2,800 a month from those health care programs to provide all care, including hospitalization, medications, home care and social services. It even pays for nursing home care when needed.
Thus, Palmetto has a strong financial incentive to keep its participants as healthy and independent as possible. The fewer days in the hospital, the less acute care they require, the less money Palmetto spends. Overall, Baskins said, the nonprofit program spends about $2,500 of its $2,800 payment each month.
But the model's success is more than financial, notes Nancy Miller, acting director of the division of long-term care experimentation for the federal Health Care Financing Administration.
Dropout rates in the existing nine sites are less than 2 percent a month and are mainly from deaths, she said. ``There is very little dissatisfaction with services,'' she said.
``What we see is more thought given to what a person's last few years will look like; that enrollees and their families are more active in making those decisions about what they'd like to have happen to them.''
The heart of PACE is an interdisciplinary team, composed of a doctor, social worker, pharmacist and physical, speech and recreational therapists. Together with the family and enrollee, they make all care decisions.
Even the transportation worker who brings members to the center is part of that team. ``The van driver sees this person every day; goes into the home, talks with the family,'' explained Baskins. ``He may notice someone's feet are more swollen than normal, and that could be a sign of heart disease. Or tell us that the house has no heat, and that's why this person can't shake a cold.''
It's an approach that internist Lisa Wilson never heard of when she was in medical school. ``The only purpose of a social worker, we learned, was to find a nursing home bed,'' she said.
Wilson, attracted by the steady hours, began working with Palmetto when she finished her residency in 1991. Eventually, she figured, she'd leave and go into private practice.
Now she's hooked on the PACE model.
``This is the best way to take care of the medically frail population. It allows us to completely coordinate their medical care, vs. them going to one doctor for their kidney problems, another for arthritis, another for heart problems.''
In this program, creativity is king and nothing is off-limits if it will improve quality of life for either the participant or the caregiver.
So when one 74-year-old participant's dog got fleas, Palmetto paid to remove them - instead of waiting until the woman had skin problems from flea bites and needed more extensive medical treatment.
An enrollee dying of painful metastatic cancer, whose daughter was stealing her pain pills, was initially recommended for a nursing home. But because the team knew she wanted to die at home, they arranged to give her narcotics through a skin patch, covered with a dressing, and told the daughter she had a skin ulcer.
And when Sarah Rhames, 69 and wheelchair-bound with arthritis, needed to get to church on Sundays, Palmetto found her a ride.
But it's not just the participant who benefits. The caregiver also receives help and support through a social worker.
``Half of everything we order is to `talk to the family, talk to the family,' '' Wilson said. ``Because often the patient can't tell you what's wrong with them.''
The program doesn't replace an elderly person's family; it merely supplements it, Baskins said.
Take Florrie Ross. When Cooper approached Palmetto about enrolling her aunt into the program, Palmetto said Cooper had to find someone to stay with her aunt at night and on weekends, when the center was closed.
An unemployed older woman took the job, which offered free room and board.
But she still makes the eight-minute drive to her aunt's house twice daily: in the morning, to get her out of bed and dressed, and at 4 p.m., when the bus from the health center drops her off.
Ross lives in the kitchen of her old house, with its peeling linoleum, grease-stained walls and cracked window shades. A small, black-and-white television, a cot and night stand have turned one part of the narrow room into a bedroom.
``I know the house needs work,'' Cooper said apologetically, ``but that just isn't my priority right now.''
Her priority is keeping her aunt well. She spends about eight hours a day cooking and freezing her meals, dressing her, getting her to bed and dealing with her financial matters.
But without the PACE program, she said, ``I could not have cared for her.
``I have peace of mind when I know she's at the center. I know she's well cared for, and when I call the physician, she knows my voice and whatever I need checked is done immediately. I don't need an appointment, I don't have to wonder if I can make it to the doctor's office to sit and wait.
``She is not going to get the same care in a nursing home. She is going to be a number in a nursing home.''
As for Big Mama, who says being 85 is a ``living hell,'' the center provides some peace in her pain. ``I don't mind going there, I can tell you. I'd rather be there than here.''
On Lok - the name is Cantonese, meaning ``peaceful, happy abode,'' - started providing senior day and health-care services in San Francisco in the 1970s. But the program assumed its present form in 1983, when it received a grant from the Robert Wood Johnson Foundation and waivers from HCFA and California's Medicaid program to test the PACE concept.
The program proved so successful that in 1986, Congress authorized On Lok to facilitate 15 other sites around the country, nine of which are operating in New York, California, Oregon, Texas, Wisconsin, South Carolina, Colorado and Massachusetts.
Sentara hopes to become the first PACE site in Virginia. It has nearly completed a feasibility study, which the state's Department of Medical Assistance Services strongly supports. Now it's up to DMAS to set a payment rate and get the necessary waivers from the federal government.
It took this long to bring PACE to Virginia, said Life Care President Steve Gold, because the system had to mature so it could take on the enormous financial risk of caring for this population, as well as develop its relationship with DMAS.
Gold isn't concerned that the program will compete with Sentara's six nursing homes. They are running at 97 to 98 percent capacity, and estimates are that only about 20 percent of nursing home residents are eligible for the PACE model.
``It's part of Sentara's strategic vision to grow the number of managed care lives in our system,'' said Gold. ``But philosophically, we're pursuing it because there have to be other alternatives available beyond institutionalization or other community-based services, and PACE represents one of the better options because it preserves the integrity of choice.'' ILLUSTRATION: Innovative Care for the Elderly
PAUL AIKEN/Staff
[Color Photo]
Stroke patient Florence Taylor, 58, tries to laugh her way through a
painful session with physical therapy assistant Marie Castor at
Palmetto SeniorCare in Columbia, S.C. Sentara hopes to bring such a
center to Virginia Beach this summer.
Judy Baskins, director of Palmetto Senior Care
PAUL AIKEN/Staff
Carol Cooper, right, has cared for her aunt, Florrie Ross, for more
than a decade. Cooper enrolled her in an innovative program in
Columbia, S.C.
Adult day care center vs. PACE center:
Participants congregate in a community center where they eat and
socialize.
Acute and preventive medical care is brought into the center.
Nursing home vs. PACE center:
Physician visits and preventive, holistic health care are rare.
Physicians, nurses and therapists are on site every day.
Nursing home and PACE center:
Participants are frail, and they must meet their state's
eligibility criteria for nursing home admission.
ABOUT PACE
How do I sign up for PACE? The program will screen applicants
before admission. Applicants and their families can call the center
directly to request a screening. A physician's referral is not
required.
How many people eventually would be served by the PACE model in
Hampton Roads? When the program reaches maturity in about five
years, it hopes to serve 600 people throughout the region. Sentara
also hopes to expand the PACE concept to other chronically ill
populations, like those with kidney disease or AIDS, and serve 200
more people.
Who is eligible? Anyone who is 55 or older and meets the state's
criteria for admission to a nursing home. Most participants are
eligible for Medicaid, but the program will accept private pay and
Medicare-only patients.
KEYWORDS: ELDERLY DAY CARE by CNB