December 16, 2021
As the Covid-19 pandemic stretches through 2021 and into 2022, how have PACE organizations—which are accustomed to treating older adults who require nursing home-levels of care from a Center—changed their protocols to keep serving participants at home, while guaranteeing delivery of all Medicare and Medicaid benefits?
To find out, we spoke with six PACE administrators in California, Massachusetts, Michigan, North Dakota, Pennsylvania, and Texas. Specifically, we asked them how they crafted targeted solutions to meet both the physical and emotional needs of participants, families, and staff. This is the fifth blog in the series as we continue to dive deep into this project.
We found that delivering food to participants was a challenge that loomed large as the pandemic caused many PACE Centers across the country to close their doors. Before Covid-19, PACE participants traveling to the Center had access to two guaranteed meals a day, up to five days a week, including an option to bring additional frozen meals home. Making sure participants had the food they needed quickly became one of the most important tasks facing PACE Centers, which had to address not only the food insecurity issues of some but also forestall people from venturing out to buy groceries.
To meet the need of participants who were homebound, PACE sites initiated daily meal preparation, packaging of orders, and grocery distribution. A PACE site in Michigan began by shopping at local grocery stores to deliver packaged and frozen meals. When the pandemic disrupted food supply chains, staff transitioned to a local farm-to-plate process. They invested in the equipment and supplies needed to package, freeze, and deliver locally produced foods—a process that they plan to continue post-pandemic. Farmers’ markets were tapped to provide fresh produce and eggs, and staff nutritionists called participants to learn about their needs and preferences. Personalized grocery deliveries that included such special requests were a major hit at a site in Pennsylvania, where an excited participant exclaimed, “Man, I never ate so good!” Another site in Massachusetts reported converting a transportation van to a refrigerated truck to continue meal delivery post-pandemic.
With participants sheltering in place, new efforts to mitigate social isolation, loneliness, and depression were another key priority. To accomplish this, all six PACE organizations adopted an “all-hands-on-deck” mentality which required staff to shift their roles. Notably, almost all staff began providing some form of direct care to participants. They made daily phone calls to check on wellness, which in times of illness were increased to every few hours. Staff also frequently treated participants at home, including physical and occupational therapists, who continued providing rehab in-person and created tailored home exercise programs.
One PACE site in Texas set up a system in which a staff member (from various disciplines) would visit participants in their homes once a week to check on them, provide services, and then stay to share a meal. At another site, staff who had not previously provided direct care were enlisted to go to participants' homes to help them bathe. The director of that program reported that while some staff were initially reluctant to perform this task, they later said they were pleasantly surprised at how valuable they felt being able to offer nurturing and intimate care to someone in need. In several programs, staff normally assigned to run group activities came up with creative ways to keep participants occupied at home. For example, participants in one PACE program were incentivized to answer a phone call for their daily wellness check with a free Bingo number each day. Most PACE sites we interviewed assembled and packed activity bags with puzzles, games, and projects to help participants enjoy their time at home more. In some cases, PACE programs were able to distribute iPads to participants to use for online activities, video communications, and telehealth visits with health care providers.
To address health care workforce shortages and keep participants safe and comfortable in their homes, one Massachusetts PACE site relies on what they describe as “a unique program called our ‘Personal Care Worker program,’ where we actually hire family members” and friends to train and care for participants. “They were the superstars of the initial pandemic,” this site’s Administrator affirmed.
The creativity of PACE adaptations takes different forms, depending on their setting. One site, in a major city, has many participants who live in the same high-rise apartment building with communal laundry facilities. To dissuade participants from gathering in shared spaces, the site developed a laundry program for the building. Participants’ laundry was picked up from their homes, brought to the center to be cleaned, and returned. The adaptation also allowed for staff who worked in the Center who otherwise may have been furloughed or laid off to be reassigned and retained. And it provided an opportunity for these staff to check in on other possible needs of participants.
Given that most PACE Centers shut down their normal operations and shifted the bulk of participants’ care to the home, it was impressive to learn of the many ways this space was repurposed. Some sites used the space to bring participants in for specialized purposes. In some cases, physical and occupational therapy was set up in large rooms with appropriate social distancing—which would not have been possible in the usually crowded exercise area. In other programs, participants who were most in need of round-the-clock care were cared for in the Center to avoid nursing home placement, and to provide their families with respite. Some Centers were even used as overnight Covid units to avoid admitting participants to hospitals that were struggling with capacity issues. Staff at one program who volunteered to stay with their overnight guests commented, “This is what we’re here for. It’s what we are supposed to do—care for our people.” Several sites functioned as vaccine clinics as soon as the first Covid-19 doses became available. In other programs, Center spaces were used as phone banks for staff to make wellness calls, as food preparation centers, as temporary food pantries utilized by both staff and participants, and as distribution centers for supplies.
As one Texas Administrator said, “we are changing to that home-based model of care… more of a hybrid…[where we] manage some of our participants in the home and not in the Center.”
PACE Centers across the country have reopened, though many remain at a reduced capacity. Social distancing and other safety precautions continue to be adhered to and balanced with participants’ needs for stimulation and social activities. Many adaptations made in the six programs we’ve described will continue into the foreseeable future. Though this is in part because Centers still have restricted access, it is also because participants liked many of the adapted services. Efficiencies have now been developed in delivering them, and they have worked to highlight new ways of caring for older and disabled adults.
As the Covid-19 pandemic slowly begins to recede, PACE organizations have been able to shift operational protocols and respond effectively to this unprecedented public health crisis. What has emerged are stories of determination and dedication, resilience and innovation, to ensure “their family” participants are cared for without interruption. In 2022, we will field another survey aimed at understanding where PACE sites are directing their energies now that they have matured in their understanding of how to provide high-touch care and support in the home.
Senior Researcher, Behavioral Health
Christine is a social and developmental psychologist who uses data and evaluation to find and implement best practices for improving the care available to older adults. She also works in the broad sphere of behavioral health contributing research to adolescent mental health and the effective treatment of substance use disorder in adults. Christine is currently the co-principal investigator on two AHRQ-funded projects; the first providing an evaluation of PACE’s Covid-19 adaptions, and the second reframing how clinicians treat pain in older adults. She holds a PhD in social psychology from the University of Michigan.
Morgan is a public health analyst in Altarum's Center for Eldercare Improvement.