Aging in place is the ability to live in one’s own home and community safely, independently, and comfortably regardless of age, income, or ability level.
In 2008 the Institute of Medicine (now the National Academy of Medicine) published a comprehensive report entitled Retooling for an Aging America: Building the Health Care Workforce. That report was intended to bring the population aging reality to public attention, especially in terms of the coming need to
- Enhance the geriatric competence of the entire workforce
- Increase the recruitment and retention of geriatric specialists and caregivers
- Improve the way care is delivered
As part of improving care delivery it sent out a call for new models of care and payment options to replace models that were not working. Finally, the report emphasized the need to empower individual patients and their families to be informed and remain active in their own healthcare. Unfortunately, most of the workforce needs are still acute, but there are some important models of care being successfully pursued (NAM, 2008; Rowe et al., 2016).
A number of successful community-focused living models are following two general paths: formal programs managed by an agency or other entity and intended to serve the needs of low-income seniors; and organized but less formal models of supportive organizations that, while open to all income levels, are helping fill the gap for middle-income seniors who wish to age in place but are being priced out of options (Goldstein, 2017; McCabe, 2019, 2018; Parker, 2019).
Program of All-Inclusive Care for the Elderly (PACE)
[This section is taken from medicaid.gov, n.d., n.d.-a.]
The Programs of All-Inclusive Care for the Elderly (PACE) provide comprehensive medical and social services to certain frail, community-dwelling elders, most of whom are dually eligible for Medicare and Medicaid benefits. In 1973 a San Francisco nonprofit started a program to help meet the needs of a growing cohort of older immigrants in Chinatown who did not want to be institutionalized away from their families in places where, among other things, no one spoke any Chinese languages. The day program founded as On Lok Lifeways eventually became the national PACE (Goldstein, 2017).
PACE model of care
An interdisciplinary team of health professionals provides PACE participants with coordinated care. For most participants, the comprehensive service package enables them to remain in the community rather than receive care in a nursing home or other care facility. Financing for the program allows providers to deliver all services participants need rather than limit them to those reimbursable under Medicare and Medicaid fee-for-service plans. The PACE model of care is established as a provider in the Medicare program and as such enables states to provide PACE services to Medicaid beneficiaries as a state option. The PACE program becomes the sole source of Medicaid and Medicare benefits for PACE participants.
Individuals can join PACE if they meet certain conditions:
- Age 55 or older
- Live in the service area of a PACE organization
- Need a nursing home-level of care (as certified by the state)
- Able to live safely in the community with help from PACE
The PACE program becomes the sole source of services for Medicare and Medicaid eligible enrollees. Individuals can leave the program at any time.
PACE benefits include, but are not limited to, all Medicaid and Medicare covered services:
- Adult daycare
- Emergency services
- Home care
- Hospital care
- Laboratory/x-ray services
- Medical specialty services
- Nursing home care
- Nutritional counseling
- Occupational therapy
- Physical therapy
- Prescription drugs (takes the place of a Part D plan)
- Primary care (including doctor and nursing services)
- Recreational therapy
- Social services, includes caregiver training, support groups, and respite care
- Social work counseling
- Transportation to PACE center and medically necessary appointments
PACE also includes all other services determined necessary by the healthcare professional team to improve and maintain an individual’s health. PACE programs provide services primarily in an adult day health center and are supplemented by in-home and referral services in accordance with the enrollee’s needs.
Since comprehensive care is provided to PACE participants, individuals who need end-of-life care will receive the appropriate medical, pharmaceutical, and psychosocial services. If the individual wants to elect the hospice benefit, they must voluntarily disenroll from the PACE program.
An interdisciplinary team, consisting of professional and paraprofessional staff, assesses an enrollee’s needs, develops care plans, and delivers all services (including acute care services and, when necessary, nursing facility services).
Minimally, the team is composed of a:
- Homecare liaison
- Occupational therapist
- PACE center supervisor
- Personal care attendants
- Physical therapist
- Primary care physician
- Recreational therapist or activity coordinator
- Social worker
The interdisciplinary team meets to ensure that the comprehensive medical and social needs of each participant are met. Teams typically meet daily to discuss the status of participants. Enrollees may be required to use a PACE-preferred doctor and will get the majority of their care from staff of the PACE organization in the PACE center. The PACE program is intended to place the focus on patients who then have a team that knows them and works closely with them and their family.
A PACE organization is a non-profit private or public entity that is primarily engaged in providing PACE healthcare services. To qualify for PACE, organizations must have:
- A governing board that includes community representation
- A physical site to provide adult daycare services
- A defined service area
- The ability to provide the complete service package regardless of frequency or duration of services
- Safeguards against conflict of interest
- Demonstrated fiscal soundness
Enrollment in the PACE program is voluntary. If an individual meets the eligibility requirements and elects PACE, then an enrollment agreement is signed. Enrollment continues as long as desired by the individual, regardless of change in health status, until voluntary or involuntary disenrollment.
PACE providers receive monthly Medicare and Medicaid capitation payments for each enrollee. Medicare enrollees who are not eligible for Medicaid pay monthly premiums equal to the Medicaid capitation amount, but no deductibles, coinsurance, or any other type of Medicare or Medicaid cost-sharing. Persons who do not have Medicare or Medicaid can pay for PACE privately.
Geriatric Resources for Assessment and Care of Elders (GRACE)
Featured on the Agency for Healthcare Research and Quality (AHRQ) Priorities in Action website are several dozen programs across the country that align with the National Quality Strategy’s (NQS) six priorities. A number of these programs benefit older adult patients, one in particular is GRACE Team Care (AHRQ, 2017).
Patients receiving medical care in today’s complex health system often interact with many physicians, nurses, medical assistants, and other trained professionals across multiple care settings—a situation especially true for the sickest populations. The Centers for Disease Control and Prevention (CDC) recently estimated that 25% of the U.S. population has multiple chronic conditions—a number that rises to 75% of adults over age 65. Treatment costs for Americans with multiple chronic conditions account for nearly 70% of the Nation’s annual healthcare costs (AHRQ, 2017a).
GRACE teams address multiple chronic conditions
Successful delivery of coordinated care among healthcare providers has been shown to improve healthcare quality and outcomes and to decrease healthcare costs. Early studies of new care delivery models prominently featured in the Patient Protection and Affordable Care Act (ACA), including patient-centered medical homes and accountable care organizations, show promise for rapidly advancing the quality of coordinated healthcare delivered to Americans with multiple chronic conditions by restructuring patients’ relationships with their primary care physicians (AHRQ, 2017a).
More than a decade ago, the Indiana University School of Medicine’s Center for Aging Research developed and implemented a program known as Geriatric Resources for Assessment and Care of Elders (GRACE) Team Care. Researchers developed the model to assist primary care physicians working with low-income seniors who have multiple chronic conditions to optimize health and functional status, decrease excess use of healthcare services, and prevent unnecessary long-term nursing home placement.
When an elder enrolls in a GRACE Team Care program, he or she receives a comprehensive in-home assessment performed by a nurse practitioner and social worker (the GRACE Support Team). This team is responsible for coordinating ongoing care for the person and it brings information learned at the in-home assessment back to an expanded GRACE team, which is led by a geriatrician and includes a pharmacist and mental health liaison who is typically a licensed clinical social worker. This larger interdisciplinary team puts together a carefully tailored care plan based on evidence-based care protocols for 12 common geriatric conditions ranging from proper medication management to vision and mobility issues to depression. If it turns out that patients have experienced many falls in the past, they will receive recommendations about stopping medications that might contribute to falls, have their vision checked, and receive a physical therapy referral for strength and balance exercises. Lessons on how to avoid falls and how to recover if they occur are also provided (AHRQ, 2017a).
After the expanded team develops a care plan for the enrollee, the support team meets with the patient’s primary care physician to review and discuss the plan. Once the plan is finalized, the support team performs a second in-home visit to align the care plan with the person’s individual goals and preferences and to work out logistics with the person and caregivers (AHRQ, 2017a).
GRACE enrollees are seen by their GRACE Support Team as needed to implement the care plan and provide ongoing care management. Enrollees are contacted by phone by their care team at least once a month, and after any hospitalizations or emergency department (ED) visits, the support team will do additional home visits. The larger interdisciplinary team meets to review the person’s care plan and determine if any changes need to be made and if anything could have been done by the team to prevent the patient’s hospitalization. Prearranged reviews of the care plan are built into the model at 3 and 6 weeks as well as 3, 6, 9, and 12 months (AHRQ, 2017a).
Focus on care transitions
A particular focus of the model is on care transitions, which can cause serious issues for senior citizens with multiple chronic conditions. The team nurse practitioner and social worker serve as advocates for the person receiving care, whatever the location. If an enrollee is admitted to the hospital, the GRACE Support Team communicates the person’s baseline status, healthcare goals, and care plan to the hospital staff and informs the patient’s primary care physician of their hospital admission. The team collaborates with hospital staff to develop an effective care transition plan before the patient’s discharge and then ensures that the plan is fully implemented. The nurse practitioner also reconciles medications and provides the patient with easy-to-understand medication instructions (AHRQ, 2017a).
For patients admitted to a nursing home, the GRACE team communicates relevant health information and care with the nursing home physician. A long-term goal of the GRACE model is to have the patient return home from hospitalization of any sort with adequate support, both to promote the patient’s happiness and well-being and to save on high-cost nursing home and acute care services (AHRQ, 2017a).
Several clinical studies confirmed the efficacy of the model, demonstrating that high-risk seniors enrolled in GRACE had fewer hospitalizations, hospital readmissions, and ED visits, as well as reduced hospital costs. A cost analysis of the intervention found that, for high-risk patients, increases in chronic and preventive care costs were offset by reductions in acute care costs. In the year after the intervention ended, the model continued to reduce costs for those enrolled. The GRACE model also received high ratings by physicians for effectively meeting the needs of older patients, and better ratings on quality indicators for both general health and geriatric conditions. Quality–of-life ratings were also higher for GRACE patients (AHRQ, 2017a; Counsell et al., 2006, 2007).
GRACE model succeeds with elders
The model’s successes, demonstrated in peer-reviewed journal articles and clinical trials, has led to implementation of the model in organizations across the country. A study published in February 2016 in PLoS One took key facets of the GRACE Team Care model and expanded the patient pool to include younger patients with multiple chronic conditions in a major urban academic medical center. Evaluation of the adapted care model found significant declines in the median number of ED visits and hospitalizations, as well as increases in the number of enrollees reporting better self-health. It has also been used successfully in a Veterans Affairs medical center (AHRQ, 2017a; Ritchie et al., 2016; Schubert et al., 2016).
Since its initial implementation at Indiana University, GRACE Team Care has been adapted to fit a wide variety of patient populations with multiple chronic conditions, across diverse healthcare settings, while maintaining positive results with regard to patient and caregiver satisfaction, healthcare quality indicators, and healthcare service utilization. The Indiana University team behind GRACE Team Care currently offers a variety of technical assistance tools and support options for organizations and healthcare systems looking to implement the model (AHRQ, 2017a).
I am in considerable denial about my own future. What you can do for me is, don’t protect me from the truth.
Member of San Francisco Village, AARP, 2015
At a time when 90% of older adults express interest in “aging in place,” yet both the costs of doing so and the costs of care alternatives can be prohibitive, the idea of Virtual Villages, which first took hold about 20 years ago, is proving popular and successful. Virtual Villages first got started in 1999 in the Beacon Hill area of Boston and the first village—Beacon Hill Village—formally began accepting members in 2002 (AARP, 2015, 2015a; Beacon Hill Village, 2019).
Today there are more than 200 villages in operation and at least 150 more in development. Grassroots and usually nonprofit Virtual Villages can be found in 45 states and Washington, DC. They are not “virtual” in the online sense but in the sense that they are not tied to a traditional municipal borderline, although they do limit themselves to geographical areas that are manageable for their purposes. The majority serve urban or suburban areas with about 13% serving rural and another 16% serving mixed areas (Graham et al., 2017; McCabe, 2018; Village to Village Network, 2019).
Most Villages are membership organizations with annual dues that average $431 (individual) and $601 (household) but range from $0 to $900 for individuals and $0 to $1,309 for household memberships. These ranges reflect the fact that many Villages offer discounts for lower-income members. In a survey done in 2016 the average number of members in a Village was 146, up slightly from the previous survey in 2012 (Graham et al., 2017).
The demographics of the surveyed Villages (about 74% of the total in existence) provide some interesting information. Age ranges are estimated to be: 13% age 64 or younger, 35% 65–74, 36% 75–84, and 22% 85 or older. Only 4% of Villages restrict membership to those over age 65 and 10% are open to all ages; the rest fall somewhere in between.
Other membership details are illuminating:
- 11% non-white
- 32% male
- 13% economically vulnerable
- 9% impoverished
- 9% have severe illness or chronic disability
- 7% LGBTQ
About 67% of Villages reported a variety of deliberate efforts to diversify membership to attract more younger members, ethnic minorities, sexual minorities, and male members. Recruitment efforts had increased since the 2012 survey but had not resulted in significant changes in membership of underrepresented groups (Graham et al., 2017).
Virtual Villages allow aging in place
The guiding purpose of Virtual Villages is to enable elders to age in place. This is accomplished with services provided by Village staff and/or volunteers, depending on each Village’s structure, or through referrals to preferred providers. The former often includes hosting social events, providing transportation, educational events or classes, companionship, technology assistance, shopping, information and referral services, home repair or maintenance, and health promotion programs. Outside providers are vetted by the Village and most often address home modification or safety assessments, home care or personal care, care coordination or social services, health promotion programs, gardening services, and technological assistance. Services vary depending on the size and talents of staff and volunteer base as well as the needs of members (Graham et al., 2017).
The future of Virtual Villages will be determined by further observation and research. The concept continues to remain popular and the number of Villages to grow. Most belong to the Village-to-Village Network, which provides mentoring and support before and after start up. Villages also tend to collaborate with regional organizations. At one time it was thought that Villages would do better if developed within an agency but that has not proven to be correct.
As Villages evolve, services provided are adjusted, what they do and who they serve is more closely defined, and issues of membership and diversity, structure and rules, staffing, volunteer support, and economic sustainability continue to be addressed (Aging in Action, 2012; Graham et al., 2017; Village to Village Network, 2019).
Naturally Occurring Retirement Communities (NORCs)
Similar to and yet different from Virtual Villages is the idea of naturally occurring retirement communities or NORCs. NORCs are usually administered by a lead social service agency and center on a residential area, such as a specific apartment building, apartment complex, or neighborhood. These are areas that were not planned as retirement housing but have evolved to have high concentrations of older adults in residence (Aging in Action, 2012; Goldstein, 2017).
NORCs like Virtual Villages
The NORC model can be traced to a program developed in New York city in the mid-1980s. An astute hospital social worker realized that the nearby South Penn high-rise apartment complex was home to many seniors who were often seen at the hospital for things that could be more effectively managed with preventive care. In conjunction with residents and the complex’s board of directors she developed a program that allowed a geriatric nurse practitioner and herself to be based at the complex and organize a range of health and social services (Goldstein, 2017).
Like Virtual Villages, NORCs support aging in place by providing services that promote and maintain healthy aging. They tend to be established by governments and nonprofits and underwritten with government funds and local philanthropy, and they utilize significant numbers of volunteers from both members and outsiders. Services most commonly include transportation, social activities, help arranging home healthcare and housekeeping services, and mental health and bereavement counseling (Goldstein, 2017; Parker, 2019).
Social activities and engagement can include all sorts of things—yoga and tai chi, English classes, workshops and lectures, supper clubs, trips to the theater, shopping, or a staff person’s translation services at medical appointments or help with insurance and Medicare forms and other bureaucracy. As with Virtual Villages, the services evolve to meet the needs of the members of an individual NORC. Often the highest need is for transportation, especially for the oldest individuals. Just having that service provided consistently and safely can mean the difference between healthy aging in place and ending up in an institution the person does not want to be in, at a higher cost to them and/or to Medicare or other programs (Goldstein, 2017; Abrahms, 2019).
As with Virtual Villages, NORCs are evolving entities and some do better than others. More recent variations on the model that include Supportive Services Programs (NORC-SSPs) have been successful in some areas. Experimentation and more research may help better identify what works and why. The Administration on Aging, which was the critical federal support for aging-in-place initiatives, was negatively affected by the most recent recession and can no longer provide the level of support it used to, forcing groups to look elsewhere for funds (Abrahms, 2019; Parker, 2019; Piturro, 2012).