March 01, 2022
The rise of Covid-19 in early 2020 plunged the U.S. and the world into an era of “remote.” Pre-vaccination, social distancing was one of the only effective mitigation strategies available, and thus many central components of our lives—from working, to learning, to grocery shopping, to interacting with health care providers—were carried out with the aid of technology.
The boom in using virtual communication platforms allowed many Americans to continue to get their needs met while remaining safely in their homes. Older and disabled adults and those that provide them long-term services and supports, however, faced unique challenges. Traditionally, the Program of All-Inclusive Care for the Elderly (PACE) model has been grounded in bringing together participants and caregivers in a center, where both medical care and supportive and social services are delivered. A substantial percentage of PACE participants are living with functional limitations and cognitive impairment, and they need a high level of attention, care, and human interaction to survive and thrive. Adding to this complexity, many older and disabled adults are not digital natives. CMS issued guidance in March 2020 allowing use of remote technology during the public health emergency for assessments, care planning, monitoring and related activities that would normally occur in-person for the PACE population. Here we discuss the uptake of technology to carry out routine PACE services.
As highlighted in previous blogs in this series, PACE administrators have been called on, in real-time, to maintain the continuity of comprehensive medical and long-term services and supports for their participants, while reworking their usual care delivery protocols to focus primarily on providing in-home care. Results from our initial survey, fielded in the second quarter of 2021, highlighted the degree of adaptation, finding that 97% of PACE programs reported a sharp increase in the use of virtual services to address pandemic-related challenges.
These services covered a wide range of interventions that had been provided in person prior to the pandemic, including primary care, rehabilitation, dietary services, behavioral health, and cognitively stimulating activities. But there was another question to consider: How pervasive was the use of this technology? Answers emerged in interviews that followed the survey from six PACE sites in diverse areas of the country—Massachusetts, Michigan, Texas, California, North Dakota, and Pennsylvania.
These conversations revealed that use of virtual service delivery in PACE was more nuanced than what the survey data suggested. For example, combining “telephone” and “video-conferencing” failed to capture the reality that frequent communication by telephone was central to the success of PACE during this time. What emerged during interviews was that communication through tablets and computers was only marginally useful, applying to 10% or fewer of PACE participants. By comparison, traditional phone use—calling rather than texting or video-conferencing—was commonly used and facilitated daily wellness checks, reminiscing to keep spirits up, assessing food and nutrition needs, and even as an around-the-clock approach for monitoring those who were quarantined due to illness or exposure. To make much higher use of telephone-based care possible, day-centers were repurposed to become more like call centers. Those manning the phones included those in all roles ranging from drivers to home care and housekeeping staff to administrative and medical staff.
Survey results and interviews also revealed that virtual delivery was better suited to some services than others. Behavioral health services were most likely to move online, with 72% of sites reporting that during the height of the pandemic more than half of all these services were being provided remotely. Virtual exercise groups were also established by some PACE organizations, as were virtual activities, e.g., bingo. Overall, this virtual delivery worked for some—but given the complexity of the PACE population and their preference to keep technology use limited primarily to the telephone, most health care and supportive services shifted from the center to in-person care delivered within participants’ homes.
In general, use of tablets such as iPads and GrandPads was less than originally hoped for by PACE administrators, who sought funding early in the pandemic to purchase the technology. Some PACE organizations established a protocol for using these devices to assist with virtual medical appointments. However, this generally involved a member of the PACE staff going to the home of a participant to help them connect to their medical or social services provider. Although this reduced the risk of possible exposure to Covid-19 for PACE participants, it added labor for PACE staff. A further complication of tablet technology is maintaining the devices in good working order, as grant funding available at the onset of the pandemic has now been largely exhausted.
By the summer of 2021, only 24% of PACE programs were reporting use of virtual service delivery at the same rate they did prior to widespread vaccine distribution. The other three-quarters of the sites said they were ramping down the use of virtual communication. Still, PACE directors predicted that home-based care, depending on continued regulatory flexibility to deliver some medical services in participants’ homes, would continue to be part of the way they will care for their participants. Most in-home care will still consist largely of in-person interactions, they said, and will not soon be replaced with care that is primarily delivered virtually.
Yet, catalyzed by the pandemic, the delivery of medical services via virtual platforms has become much more routine and will likely evolve within PACE as well. What is still in its relative infancy though, is evidence-based best practices for where, when, and how to use telehealth. In an influential book published on this subject two decades ago, Adam Darkin argued that “telehealth programs can support clinicians in developing guidelines by establishing a culture to support setting standards, devising protocols/guidelines, and instituting training and education.” As more evidence accumulates about what contextual factors promote effective telemedicine, the best uses of virtual care in the PACE model of care will become clearer. What will also provide clarification are evolving standards around reimbursement for virtual visits with providers. Here too, an evidence base will need to be gathered to support policy recommendations. In a 2012 systematic review of the use of telemedicine in treatment of chronic disease, Richard Wootton of the Norwegian Centre for Integrated Care and Telemedicine urged that stakeholders develop “a minimum dataset” with relevant information that allows an objective assessment of the cost and effectiveness of this type of care. Of course, the continued use of telehealth in PACE will all be dependent on CMS adopting regulatory flexibilities that for now are just temporary measures to address the emergency of the pandemic.
With a combination of phone communication and caregivers traveling to participants’ homes, a wider swath of our growing population of older and disabled adults may choose to enroll in PACE – including those who may not wish to attend the day center on a frequent basis. Scaling the PACE model to Medicare beneficiaries will only be possible if a policy barrier that we refer to as the “PACE Part D dilemma” is addressed—lowering the sky-high Part D premiums they must now cover out of pocket. Further into the future, as the population of the “younger old” who have more familiarity with using technology as a regular part of their lives grows, PACE seems poised to incorporate more virtual services. During the pandemic, PACE has already pivoted to adapt its center-based model to one that can also effectively deliver services primarily in the home. And while remote care is now a reality, the importance of human interaction that makes PACE such an asset for the beneficiaries it serves remains a hallmark of the program.
Program Director, Delivery System TransformationAreas of Expertise
As a psychologist, Christine brings a research and evaluation perspective to improving care services for elders and the disabled at a systems level. Through the design and execution of unique research protocols and tools, she works to build an evidence base for best practices around quality-of-life improvement and the person-centered care model. Using insights gained through empirical methods, she advocates for PACE expansion and comprehensive culture change in nursing homes.
Program Director, Delivery System TransformationAreas of Expertise
Anne Montgomery develops policy and research initiatives that improve long-term services and supports and medical care for older adults receiving services from Medicare, Medicaid, the Older Americans Act, and other programs. She is co-leading efforts to implement and evaluate comprehensive culture change and quality improvement in nursing homes and is working with colleagues to develop a new volunteer-based Community Care Corps program at the national level. Anne conducts workforce policy analysis for home and community-based services (HCBS) and advises on how to expand models of community-based care for older adults requiring complex services.