In order to improve medical care for the increasingly older American population, three areas of change are recommended by the National Institutes of Medicine (IOM):
Congress passed the Older Americans Act (OAA) in 1965 to address a lack of community social services for older persons. The original legislation provided grants to states for community planning and social services, research and development projects, and personnel training in the field of aging. The law also established the Administration on Aging (AOA) to administer the newly created grant programs and to serve as the federal focal point on matters concerning older persons (AOA, 2010c).
Although older individuals may receive services under many other federal programs, today the AOA is considered to be the major vehicle for the organization and delivery of social and nutrition services to this group and their caregivers. It authorizes a wide array of service programs through a national network of fifty-six state agencies on aging. The AOA also includes community service employment for low-income older Americans; training, research, and demonstration activities in the field of aging; and vulnerable-elder rights protection activities. The most recent reauthorization of the AOA was in 2006 (AOA, 2010c).
The Program of All-Inclusive Care for the Elderly (PACE) is authorized by the Balanced Budget Act of 1997 (BBA) that features a comprehensive service delivery system and integrated Medicare and Medicaid financing. PACE is a capitation system that pays a set amount of money for each enrolled person to that person’s assigned physician. Payment is based on the average calculated healthcare utilization of that person (whether or not the service is used) over a certain period of time. It is designed to keep patients in the community as long as medically, socially, and financially possible (medicaid.gov, n.d.).
The program is modeled on the system of acute and long-term care services developed by On Lok Senior Health Services in San Francisco, California. The PACE model was developed to address the needs of long-term care clients, providers, and payers. For most participants, the comprehensive service package permits them to continue living at home while receiving services rather than be institutionalized. Capitated financing allows providers to deliver all the services participants need rather than be limited to those reimbursable under the Medicare and Medicaid fee-for-service systems (medicaid.gov, n.d.).
All PACE centers include adult daycare that is made up of nursing, physical, occupational and recreational therapies, meals, nutritional counseling, and personal care. A PACE-employed physician oversees all primary care. A dentist, audiologist, optometrist, podiatrist, and speech therapist may also be on staff. All prescription and non-prescription medications are paid for by PACE, and home healthcare (as well as social services, respite care, and hospital and nursing home care) is coordinated from the site (Larson, 2002).
Participants must be at least 55 years old, live in the PACE service area, and be certified as eligible for nursing home care by the appropriate state agency. The PACE program becomes the sole source of services for Medicare and Medicaid eligible enrollees (medicaid.gov, n.d.).
An interdisciplinary team, consisting of professional and paraprofessional staff, assesses participants’ needs, develops care plans, and delivers all services (including acute care services and, when necessary, nursing facility services) which are integrated for a seamless provision of total care. PACE programs provide social and medical services primarily in an adult daycare center, supplemented by in-home and referral services in accordance with the participant’s needs. The PACE service package must include all Medicare and Medicaid covered services, and other services determined necessary by the interdisciplinary team for the care of the PACE participant. PACE providers assume full financial risk for participants’ care without limits on amount, duration, or scope of services (medicaid.gov, n.d.).
The majority of older adults receive healthcare in primary care settings, yet many fail to receive the recommended standard of care for preventive services, chronic disease management, and geriatric syndromes. The GRACE model of primary care for low-income seniors and their primary care physicians (PCPs) was developed to improve the quality of geriatric care in order to optimize health and functional status, decrease excessive healthcare use, and prevent long-term nursing home placement (PubMed.gov. 2006).
The catalyst for the intervention is the GRACE support team, consisting of a nurse practitioner and a social worker. Upon enrollment, the GRACE support team meets with patients in their home to conduct an initial comprehensive geriatric assessment. The support team then meets with the larger GRACE interdisciplinary team (including a geriatrician, pharmacist, physical therapist, mental health social worker, and community-based services liaison) to develop an individualized care plan, including activation of GRACE protocols for evaluating and managing common geriatric conditions (PubMed.gov, 2006).
The GRACE support team then meets with the patient’s PCP to discuss and modify the plan. In collaboration with the PCP, and remaining consistent with the patient’s goals, the support team then implements the plan. With the support of an electronic medical record and longitudinal tracking system, the GRACE support team manages and coordinates care across multiple geriatric syndromes, providers, and sites of care (PubMed.gov, 2006).
The huge cost of putting older Americans in nursing homes and other institutional settings is not affordable in this time of economic hardship and tight resources. Although there have been billions of dollars spent to provide medical care to older Americans, there have been almost none spent to keep them healthy and living independently in their homes (Moeller, 2011).
Virtual villages help older adults age in place. The villages, scattered around the United States, are membership-driven communities open to older people residing in a particular service area. Begun in Boston in 2001, there are currently 65 “villages” nationwide and 120 more in development. The villages are volunteer-driven and are “meant to help seniors continue to live in their homes by delivering a multitude of services they no longer can do for themselves and to help them stay engaged through social events” (Bohan, 2011).
Services may include a range of low-cost home, medical, shopping, social services and activities to senior members. There are yearly dues ranging from $35 to $900 with many offering discounted rates. The villages often serve middle- or upper-middle-class older adults who may fall through the cracks of the American healthcare system (Bohan, 2011).