America
is aging. In response, governments, health care providers and citizens
across the country are seeking ways to better serve the growing
number of elderly persons, particularly persons at risk for permanent
nursing home placement. The search for solutions in rural areas,
however, often is complicated by a relative lack of health care
providers and facilities, long distances between patients and services,
and lower population densities. Fortunately, help could be on the
way.
PACE: A Rural Possibility
Since 1983, Programs of All-inclusive Care for the Elderly (PACE)
have been serving frail senior citizens in ways that enable them
to live as independently as possible, keeping them in their own
homes and communities. The model began in San Francisco as an effort
to help Chinese-American families keep their elders with their families
and in their communities. It accomplished this goal by offering
a comprehensive set of services including medical care, physical
and occupational therapy, nutrition, transportation, respite care,
and socialization that kept people happier and healthier. It also
created a way to pay for this care using federal, state and private
funds that can be pooled at the program level, allowing maximum
flexibility, effectiveness and even cost-savings.
- PACE serves persons who are:
- 55 or over
- Certified to meet their state's criteria for
nursing home level of care
- Living in a designated PACE service area
- Able to live safely in the community, with
the help of PACE services, at the time of enrollment
The success the PACE model has demonstrated in
keeping people out of hospitals and nursing homes has inspired providers
around the country to adopt this model of care. Today, there are
32 PACE programs operating in 18 states. All of these programs,
however, serve predominantly urban settings. That need not be the
case. Rural communities and rural elders can and should benefit
from PACE programs.
The need for PACE in rural communities is in some
ways greater than in urban America. Compared to their urban counterparts,
the rural elderly:
- report worse health status;
- are generally older;
- have more functional limitations;
- are more likely to live alone at age 75 and
older;
- are more likely to be poor or near poor; and
- are at greater risk of being placed in a nursing
home.
Although one-fifth of the nation's elderly live
in rural areas, many of these areas lack the full range of long
term care services that rural elders need. PACE can help meet some
of this need.
A Flexible Blueprint
Undoubtedly, bringing PACE to rural America will require creativity
and flexibility on the part of providers, regulators and policy
makers. Because rural communities differ from urban areas in some
very important aspects, rural PACE programs will likewise differ
from urban programs. One size will not fit all. Successful PACE
programs are tailored to meet individual community needs rather
than being pulled from a rack, ready to wear.
PACE programs are able to effectively serve elders
in the community by being flexible and bridging the gaps that often
exist in today's health care. PACE programs have several basic features
that enable them to tailor their care and services to the needs
and situation of each individual.
- A focus on empowering individuals to live in
the least restrictive and most pleasing setting possible
- Interdisciplinary teams composed of persons
who are both providers and decision-makers for the health care
and supportive services each PACE participant receives
- A capitated payment that pools financial resources
from government and private payers so that providers have the
freedom to offer preventive and wholistic care and support that
often can postpone or avoid the need for more intense acute or
long term care
- A responsibility to provide or pay for the
provision of all needed preventive, acute and long term care services
so the organization has a financial incentive to provide the best
and most effective care possible
Rural Challenges and Emerging Strategies
In September 2002, PACE providers and rural health experts, along
with state and federal policy makers from across the country, gathered
in Roanoke, VA, to explore the possibilities for PACE in rural communities.
This "Rural PACE Summit" was sponsored by the National
PACE Association (NPA) and the National Rural Health Association.
Its findings are captured in a report entitled "Setting the
PACE for Rural Elder Care: A Framework for Action." Participants
at the Summit identified some of the critical issues and challenges
that rural organizations will face in adapting the PACE model:
- Staffing
- Financing and Risk Management
- Developing the Necessary Infrastrucute
- Using Information Technologies
As part of the Rural PACE Technical Assistance
Program, funded by the Health Resources and Services Administration,
NPA convened workgroups of rural health and PACE providers to further
discuss these issues. The results of the workgroups' discussions
are presented in this series of issue briefs designed to help rural
organizations identify and meet the challenges they will face in
bringing the PACE model to their service areas.
Issue 1: Recruiting and Retaining Staff
Overcoming workforce shortages remains one of
the most daunting challenges for health care providers in the 21st
Century-especially in rural areas. Acquiring and maintaining adequate
staffing is crucial to the success of any rural health care provider,
but none more than rural PACE programs, for whom staffing challenges
may be even more difficult.
Because PACE provides such a comprehensive range
of care (everything from nursing, social work and physical therapy
to prescription drugs, surgery and nursing home care), PACE programs
require staff in virtually every field of health care. In addition,
they must coordinate and manage that wide range of staff. Finally,
rural PACE programs operate in areas that are typically underserved
by health care professionals, and involve sparse populations, long
distances, and a relative lack of infrastructure. Fortunately, a
number of strategies drawn from rural health care suggest how the
PACE model might be adapted to meet these challenges.
Challenges and Strategies
Challenge 1: Recruiting and Retaining Qualified Staff
Like other health care providers, prospective
PACE providers will likely find it difficult to obtain and retain
skilled professionals in rural communities. Some may find it difficult
to compete for staff with nearby urban providers. For example, a
health care provider recruiting staff in rural Kentucky reports
that in 2004, salaries for registered nurses in rural Leslie County,
ranged from $65,000 to $75,000, while in urban Louisville registered
nurses earned only $55,000 to $60,000. Thus, rural health care providers
may be forced to offer higher salaries than those offered in nearby
metropolitan areas in order to attract qualified staff.
For other programs, distance may necessitate hiring
multiple part-time people instead of a single full-time position
to ensure timely service to participants in their homes. Doing so
may make it difficult to attract qualified individuals looking for
full-time work and benefits.
In addition, federal PACE regulations prescribe
personnel qualifications for PACE staff, which may be difficult
to obtain in a rural area (e.g., that a social worker have a Masters
of Social Work degree).
Finally, the ongoing recruitment and training
of new staff in rural areas is expensive. This administrative expense
may not be accounted for in the methodologies used to establish
capitated Medicare and Medicaid rates for PACE. Other expenses incurred
by rural health care providers may not be reflected in the existing
Medicare wage index, which is used in the calculation of other Medicare
payment systems and generally reimburses rural providers at a lower
rate than their metropolitan counterparts.
Strategy 1a: Provide grants and/or subsidies
to informal caregivers. Due to a lack of health care personnel
in rural areas (especially the broad range of personnel needed by
a PACE program), rural PACE programs will likely rely on family
members, neighbors, friends, church members, volunteers and senior
centers to help deliver care. Indeed, participants and family members
are considered important members of the interdisciplinary team in
PACE. To help facilitate the involvement of these informal caregivers
and offset their costs, some existing PACE programs provide them
with subsidies or grants. Some states offer similar compensation
to family and community caregivers. For example, the State of Colorado
pays family caregivers $400 per month to provide home health care.
Similarly, the State of Wisconsin compensates family members and/or
neighbors for providing direct care that is normally provided by
a social worker.
Strategy 1b: Be flexible and innovative.
Given the limited resources available in rural communities, prospective
providers may need to contract for a wider range of PACE services
than has historically occurred in metropolitan areas. Whether staffed
directly or through contracts, flexibility will be important for
PACE programs to serve rural communities. Section 460.102(f) previously
required that the following interdisciplinary team members be employees
of the PACE organization: primary care physician, registered nurse,
social worker, recreational therapist or activity coordinator, PACE
center manager, home care coordinator, and PACE center personal
care attendants. However, with the passage of the October 1, 2002
interim federal regulation, the federal government no longer requires
that the PACE organization directly employ the interdisciplinary
team, the program director or the medical director.
While some states and PACE providers report that
current federal regulations can make it difficult to contract for
certain types of services, such as home care or adult day care,
it is possible to file for a waiver to obtain more flexibility in
these areas. For example, PACE Vermont is requesting waivers for
the federal regulation requirement that members of the interdisciplinary
team must serve primarily PACE participants and the requirement
that the primary care physician must be an employee of the PACE
organization. They plan to contract with other community health
care providers to co-locate the PACE center with an existing successful
adult day program to reduce facility costs and account for a small
census. Rather than rely on a single physician, they plan to rely
on a group practice, which they believe will give them the advantage
of back-up, on call, and linkages with area hospitals that will
ensure availability of physician expertise at all hours.
States also may want to ask the Centers for Medicare
and Medicaid Services (CMS) to waive the Master's of Social Work
or other similar requirements for staff or to include an equivalent
but broader range of education and personnel qualifications required
under 42 CRF § 460.64 to enlarge the pool of individuals who
qualify for specific positions.
Strategy 1c: Dangle the big carrot.
Rural health care providers are generally creative and quite generous
when recruiting staff from other communities. For example, some
providers offer to make a down payment or pay closing costs on a
home, help sell a home in the community the individual is leaving,
absorb re-location expenses, or find employment for the spouses
of new hires. In addition to flexible hours, adequate pay and educational
opportunities, some existing PACE programs provide staff with company-owned
vehicles to deliver home care. This practice not only helps offset
the low salaries many of these workers receive, it also conveys
respect for staff's personal property and helps ensure their safety
while traveling for work.
Strategy 1d: Foster a new resource pool.
Some rural health care providers create interest in nursing by educating
students in junior high and high schools about the field, funding
and recruiting students to participate in nursing summer camps and
workshops, funding nursing education, and helping to repay employees'
student loans. Area Health Education Centers develop health careers
recruitment programs in underserved rural areas. The centers also
provide educational support and technical assistance to reduce professional
isolation and increase retention.
Strategy 1e: Ensure Medicare and Medicaid
rates adequately compensate rural providers. States and
providers may want to explore with CMS opportunities to increase
reimbursement rates to help rural PACE providers address recruitment
and retention issues or help them compensate for the fact that they
may require an increased number of staff to serve participants across
larger distances. Some work may need to be done to improve the Medicare
Wage Index Floor for rural areas to ensure providers can offer the
salaries needed to draw staff from nearby metropolitan areas. Similarly,
Medicaid rates should compensate rural providers for the recruitment,
training and retention expenses that rural programs will incur on
a continuing basis.
Strategy 1f: Cultivate community partnerships
and share limited resources. Given the limited resource
base of most rural areas, the lack of competition and the common
challenges shared by all, partnerships often are more easily built
in these communities. One way to overcome limited staffing resources
in rural areas may be to share specialty or support staff with nearby
PACE programs or other health care, transportation or social service
providers. Such collaborations are common in community health centers
and hospitals that share physicians in order to address liability
issues. In addition, there may be opportunities for PACE providers
to partner with universities or local colleges to utilize nursing,
dental, social work, physical therapy or occupational therapy students
with supervision.
Challenge 2: Coordinating an Interdisciplinary
Team, Multiple Partners and Various Contractors in Various Locations
At least some members of a rural PACE program's
interdisciplinary team are likely to be contracted rather than employed.
Interdisciplinary team members may work in different areas or communities,
especially in the event that a rural PACE program is designed with
alternative care sites and/or home care. All of this can hinder
coordination and communication among staff.
Strategy 2a: Use technology. Advanced
information technologies enable many rural health care providers
to deliver and coordinate care across long distances and can do
the same for rural PACE programs. For example, video, computer or
phone line teleconferencing can enable the interdisciplinary team,
field staff and contracted staff to meet and coordinate care across
miles. It also can help with oversight and monitoring.
Though such technologies are not available in
every rural community, by being flexible and innovative, rural PACE
programs can access and use them. Programs may need to seek out
partners such as community colleges or other institutions outside
the health care field in order to gain access to these technologies.
(See Issue 4: Using Information Technologies.)
Strategy 2b: Cross-train staff. Staff
working in a rural PACE program may require more cross-training
given the limited resources available and in order to ensure that
those providing care in the field are sensitive and aware of symptoms
or conditions that should be reported to other interdisciplinary
team members and to limit the number of people intruding in a participant's
home.
Challenge 3: Obtaining Access to Training
Training for staff can be difficult to obtain
in rural areas. Few rural areas have training resources locally,
and travel budgets and backup personnel to allow staff to attend
training events elsewhere can be hard to come by for professional,
paraprofessional and administrative staff.
Strategy 3a: Utilize existing PACE programs
to train staff. PACE providers report that most training
for PACE is conducted on the job, particularly with respect to the
interdisciplinary team. Many existing PACE providers offer programs
to train new staff on the interdisciplinary team. They also provide
one-to-one training for PACE specialists. In addition, PACE providers
often offer cultural and demographic education and training. Consequently,
opportunities exist for new PACE providers in rural communities
to partner with established PACE providers to meet their training
needs.
Strategy 3b: Draw on community resources.
Some rural hospitals, nursing homes and social service programs
utilize lay people and volunteers to help offset staffing shortages.
In many cases, these providers offer to others their training programs,
which may not be as extensive as state-certified training, but do
build the necessary skills for a lay person to perform a specific
function and qualify that individual to work in a very limited capacity.
In addition, other community resources such as economic development
agencies, grade schools, community colleges and university programs
offer various training opportunities. These training programs could
be utilized and/or used as templates to develop in-house training
programs for PACE providers.
Strategy 3c: Use technology. Advanced
information technologies can give rural providers remote access
to training programs held elsewhere-eliminating the need to have
the training locally or travel to it.
Challenge 4: Overcoming Bias Against Outsiders
People are more likely to prefer health care providers
who share their culture and are established in the community over
those perceived as "outsiders." Because rural PACE providers
likely will need to draw upon staff from outside the local community,
problems with trust may arise-especially with respect to home care,
when providers come into a participant's house.
Strategy 4a: Ensure staff is sensitive to
the local, rural context. When staff from outside the community
is used, the PACE program will need to build trust among the staff
and participants by ensuring that the staff understands the local,
rural context (including the cultural values and faith practices
of tribal communities)
and acts accordingly. This is especially important given all the
staff likely to enter participants' homes.
Staffing Resources
Several federal and state programs help increase
and maintain the health care workforce in rural areas:
- The National Health Service Corps (NHSC) provides
scholarships and loan repayment to physicians and other health
professionals who agree to serve in rural and urban underserved
areas. The NHSC State Loan Repayment program provides funds to
the states for their own loan repayment programs (http://nhsc.bhpr.hrsa.gov).
- Area Health Education Centers extend the resources
of academic health centers into rural areas by recruiting students
to health care careers and providing clinical training opportunities
to health professionals and nursing students (www.aamc.org/advocacy/hpnec).
- The Quentin Burdick Rural Interdisciplinary
Training Program provides grants to improve access to health care
services in rural areas by increasing the recruitment and retention
of health professionals in these areas. The program funds projects
to develop new and innovative methods to train health care practitioners
to provide services in rural areas (www.aamc.org/advocacy/hpnec).
- The Nurse Reinvestment Act of 2002 establishes
scholarships in exchange for commitment to serve in a public or
private non-profit health facility determined to have a critical
shortage of nurses. It assists health care facilities in retaining
nurses and improving patient care through increased collaboration
among nurses and other health care professionals, and by increasing
the involvement of nurses in the decision-making process. The
Act provides for programs to train and educate individuals in
providing geriatric care for the elderly and establishes partnerships
between health care providers and schools of nursing for advanced
training. It also helps nurses obtain more education (http://bhpr.hrsa.gov/nursing/reinvestmentact.htm).
Conclusion
While rural PACE programs face many challenges, many strategies
are available to help them overcome those challenges. Using the
strategies described above, along with others, rural PACE programs
can acquire and maintain the staffing needed to succeed.
Issue 2: Managing Risk
In addition to the liability risks faced by all
health care providers, PACE programs also face financial risk because
they receive a fixed, prospective payment on a monthly basis. Because
payment is not based on the PACE program's costs, the PACE provider
is at financial risk for managing the costs of the care it provides
within the limits of the payments it receives.
Rural PACE programs' ability to manage financial
and liability risks may be further challenged by several characteristics
of rural areas, including dispersed populations and a scarcity of
health care services. Fortunately, a number of strategies drawn
from rural health care suggest how the PACE model might be adapted
to meet these challenges.
Challenges and Strategies
Challenge 1: Achieving Adequate Enrollment
When it comes to financial risk, size matters.
As enrollment increases, the average fixed costs of operation decrease.
When that happens, revenues are more likely to cover costs. Revenues
over and above those needed to cover costs can be used to establish
a risk reserve with which to cover outlier expenses that exceed
the monthly payments received for any individual. Unfortunately,
enrollment may grow slowly in rural PACE programs. As a result,
it may take longer to reach "break-even" enrollment and
establish a risk-reserve fund, leaving the programs more exposed
to risk.
Strategy 1a: Serve a larger area. Rural
PACE programs can meet the challenge of sufficient enrollment by
modifying the delivery of care to extend services over a larger
geographic area. The larger geographic area can offset the lower
population density and enable the PACE program to establish higher
levels of enrollment.
Strategy 1b: Work with trusted sponsors.
Rural PACE programs can ally themselves with rural health care providers
already known and trusted within the community. This can help enrollment
by, among other things, reducing concerns that the PACE program
will disappear as managed care companies may have done in the past
when faced with financial difficulties.
Strategy 1c: Link with other PACE programs.
Rural PACE providers can link with urban PACE providers or other
nearby rural providers to share fixed costs and facilitate access
to required health professions and services. This strategy has been
applied in South Carolina to extend services from an urban center
into an adjacent rural area. Similarly, a program in Wisconsin has
used an outreach location linked to its central site to serve a
more rural population.
Strategy 1d: Tap into a wide range of payer
types. Because of their history of providing care to all
members of a community, rural PACE providers may be able to attract
private-pay individuals-increasing enrollment and diversifying the
payer mix. Private payments supported by individuals' long term
care insurance benefits also may have the potential to increase
enrollment opportunities for rural PACE programs. Rural PACE programs
also may have opportunities to serve veterans and receive payment
from the Veterans Administration.
Challenge 2: Ensuring Adequate Operating Revenues
The lower Medicare and Medicaid reimbursement
rates for rural areas upon which PACE capitation rates are based,
in combination with higher per-unit costs of service, challenge
rural PACE providers' ability to obtain adequate operating revenues.
Strategy 2a: Contain costs of inpatient
care. In establishing hospital contracts, rural PACE providers
may be able to set a per-diem rate with a provision that total costs
of an episode of care not exceed the Diagnostic Related Groups (DRGs)
payment, thus helping to contain hospital costs. For hospitals not
under contract to the PACE organization, charges are limited by
federal statute to what Medicare or Medicaid would pay.
Strategy 2b: Contain costs of outpatient
care. Rural PACE providers can ask health professionals
to accept a per-enrollee, per-month fee. In exchange for this fee,
the health professional would be available to provide services to
a PACE enrollee as needed. This arrangement can be used to reduce
the costs of specialist care, primary care and therapy until enrollment
levels support a salary for these professionals.
Strategy 2c: Utilize enhanced state/federal
payments during start-up. States can pay PACE programs a
higher Medicaid capitation rate during start-up phase (e.g., 100
percent of upper payment limit). These enhanced payments can help
offset initial operating losses of the PACE program while it grows
its enrollment. State incentive payments for taking people out of
nursing homes and returning them to a community setting also can
provide additional revenues to a rural PACE program.
Strategy 2d: Ensure that full costs of comparable
care are considered in setting the PACE rate. Rural PACE
programs will need to work with state Medicaid agencies to establish
a PACE rate that captures the full costs of providing comparable
care to a comparable population. Notably, transportation costs will
be high for rural PACE. State rates for PACE should consider the
comparable transportation costs of existing programs.
Challenge 3: Gaining State Commitment to Funding
Funding for rural programs by states varies but
tends to underestimate the costs of care in rural areas, which often
are higher than costs in urban areas. In general, state funding
for new programs is very limited.
Strategy 3a: Show how PACE saves money.
PACE programs cost less than nursing homes and can be a
way for states to lower their long term care budgets.
Strategy 3b: Show how PACE creates jobs.
PACE programs create jobs in communities by operating and providing
care in the community setting. This can help revitalize economically
challenged areas.
Challenge 4: Sharing Risk
Because risk is not shared by the rural PACE provider
and its payers, programs are challenged to find ways in which they
can share risk in order to limit their total risk exposure.
Strategy 4a: Obtain reinsurance.
Rural providers can purchase reinsurance policies currently available
that limit their risk exposure for hospitalizations. In addition
to private reinsurance, some states offer state-funded reinsurance.
Vermont is developing a Medicaid reimbursement rate for PACE that
includes protection against outlier expenses while the rural provider
builds census. Rhode Island is looking at a similar payment design.
States also have maximized the Medicaid PACE rate at 100 percent
of the upper payment limit (indefinitely or for some period of time
while the program grows).
Strategy 4b: Pool risk reserves.
Rural providers may be able to seek funding support from foundations
to develop a pooled risk reserve shared across multiple providers
during an initial period of program growth. Rural providers affiliated
with a faith-based organization may be able to have the organization
create a pooled risk reserve for all of its affiliates.
Challenge 5: Managing Care
Effectively managing care requires an interdisciplinary
team with the ability to collaborate in care planning and implementation.
In rural areas, PACE providers may contend with a lack of staff,
difficulties in convening the health professionals involved in an
individual's care, and a population that is sicker due to prior
years of inadequate access to health care.
Strategy 5a: Use community providers.
To manage care across a large geographic area, rural programs can
work with community physicians.
Strategy 5b: Use telemedicine. Many
rural providers have experience in using telemedicine. This experience
can be applied to ensuring adequate care management and disease
prevention in a rural PACE population.
Challenge 6: Managing Network Services and
Professionals
Because rural PACE programs will need to contract
with a wide range of providers, managing those providers will be
crucial. In addition, providers who are the sole sources of care
in their area may not wish to contract with a PACE program on a
defined-cost basis, thus increasing the risk of open-ended costs.
Strategy 6a: Monitor high-cost, high-frequency
utilization. To improve the management of network services,
PACE programs can generate and review information on patterns related
to high-use and high-cost services.
Strategy 6b: Establish a contact for each
network provider. Regular communication with a contact person
for each network provider regarding PACE enrollees in their care
can help integrate the practice of the network providers with the
services of the program. For example, assigning a registered nurse
to monitor care provided to a PACE enrollee during an inpatient
stay integrates services more effectively and limits unexpected,
and unnecessary, costs.
Challenge 7: Covering Liability Risk
It may be difficult for relatively small rural
providers to acquire liability insurance for medical malpractice
or coverage for directors and officers. If rural PACE programs rely
more on home care, increased liability associated with a caregiver's
unsupervised time with an enrollee may be an issue. Liability for
providing emergency care may be a high risk for rural PACE programs,
as these services often are unavailable or rely on volunteers. Some
programs may be further exposed to risk by the absence or limitations
of 911 service. Finally, rural PACE staff are likely to travel frequently
in the course of their duties, adding to the program's liability
risk.
Strategy 7a: Partner with Federally Qualified
Health Centers (FQHCs) and Community Health Centers (CHCs).
PACE programs sponsored by FQHCs or CHCs have the benefit
of the protections against liability enjoyed by those types of organizations.
Conclusion
While rural PACE programs face many challenges, many strategies
are available to help them overcome those challenges. Using the
strategies described above, along with others, rural PACE programs
can develop comprehensive risk management programs needed to succeed.
Issue 3: Developing the Necessary
Infrastructure
Like all health care providers, PACE programs
require adequate infrastructure in order to provide high-quality
care in a cost-effective manner. Programs need a range of staff
and services and the systems to manage them. They also need sufficient
demand to pay for it all. To date, most PACE programs operate in
metropolitan areas with both extensive health care infrastructure
and high concentrations of eligible seniors. As a result, they are
able to sustain themselves financially.
Due to the nature of rural areas-fewer people
spread over larger geographic areas-few rural areas have the extensive
health care infrastructure or the highly concentrated market that
urban areas do. Consequently, rural PACE providers will face different
challenges than those faced by urban providers and will require
different strategies to meet those challenges. Fortunately, a number
of strategies drawn from rural health care suggest how the PACE
model might be adapted to meet these challenges.
Challenges and Strategies
Challenge 1: Maintaining Face-to-Face Interaction
Between Participants and Interdisciplinary Team (IDT) Staff
Because rural PACE participants likely will be
spread over larger distances and members of the IDT likely will
not be housed in one location, maintaining adequate face-to-face
interaction between participants and staff will be a challenge.
Strategy 1a: Use alternative care
sites and other settings such as senior housing facilities, assisted
living facilities and churches to deliver specific services. By
reducing reliance on the "one center" model of PACE delivery
and using existing facilities located near those seniors, rural
providers can more easily and more cost-effectively reach seniors
spread out over greater distances and maintain face-to-face interaction
with participants.
Strategy 1b: To the extent state
regulations allow, use community and family caregivers to minimize
reliance on PACE staff. By reducing reliance on traditional PACE
staff and using caregivers in the home or community, rural programs
can increase face-to-face interactions between caregivers and participants.
Note: Obviously, the use of community and
family caregivers entails training. It also demands oversight and
coordination. One way to meet those demands is to involve community
and family caregivers in interdisciplinary team meetings-at alternative
care sites, via telecommunications or, at times, at a central location.
Strategy 1c: Utilize advanced telecommunications
technologies. By linking PACE providers with participants,
telecommunications offer opportunities to increase interaction,
albeit at a distance.
Note: Unfortunately, some advanced telecommunications
are quite costly and some are not yet available in all rural areas.
In some instances, PACE providers may need to work with other entities
outside the health care field in order to utilize their telecommunications
facilities (e.g., community colleges) and/or aggregate enough demand
to warrant the building of additional telecommunications facilities.
Challenge 2: Paying for Transportation
Sparse participant population spread over wide
areas means that transportation will be a major factor-as it is
for rural health care in general. The costs of providing that transportation
for participants, as well as providers, may well be one of the tougher
challenges faced by rural PACE providers.
Strategy 2a: Use alternative care sites
and other settings such as senior housing facilities, assisted living
facilities and churches to deliver specific services. The
use of alternative sites can reduce the need for, and cost of, transportation.
Strategy 2b: To the extent state regulations
allow, use community and family caregivers to minimize reliance
on PACE staff. Using caregivers in the family or community
can reduce the need for, and cost of, transportation for staff and
participants.
Strategy 2c: Increase emphasis on home care
as an alternative to day center attendance. By using home
care, rural programs can reduce the costs of transporting participants.
Strategy 2d: Utilize advanced telecommunications
technologies. By linking PACE providers with participants,
partnering medical personnel and other contractors, telecommunications
can reduce the costs of travel and transportation.
Strategy 2e: Build a coordinated network
between multiple rural health care providers interested in sponsoring
a PACE program and contractors necessary to operate a program.
Creating a network of distinct community based transportation providers
will "localize" transportation services and create efficiencies
by eliminating driving time between communities that would occur
if only one transportation contractor were utilized.
Note: The use of partnerships and contracts,
of course, requires a high level of training, oversight and coordination
to ensure that services are provided in the most cost- and quality-effective
manner.
Challenge 3: Managing Multiple Partners and
Contractors in Multiple Communities
Having staff spread over distance presents several
obstacles to effective management and coordination.
Strategy 3a: Utilize advanced telecommunications
technologies. Telecommunication links, between PACE providers,
partnering medical personnel and other contractors, offer a cost-effective
way to coordinate care and services and enhance oversight.
Strategy 3b: Build a coordinated
network between multiple rural health care providers interested
in sponsoring a PACE program and contractors necessary to operate
a program. Assembling a team from multiple rural health
care organizations can create a management infrastructure to support
staff working in the field. This management team of linked organizations
can design, implement and manage efficient and effective approaches
to PACE program operations.
Challenge 4: Obtaining Trained Medical Specialists
and PACE Program Staff in Rural Areas with Which to Build and Maintain
Adequate Staffing
All rural health care providers face difficulties
in obtaining and retaining adequate staff. The challenge for rural
PACE providers likely will be even greater, given the need for so
many different types of professionals.
Strategy 4a: To the extent state regulations
allow, use community and family caregivers to minimize reliance
on PACE staff. By reducing reliance on traditional PACE
staff, rural programs can overcome workforce shortages.
Strategy 4b: Utilize advanced telecommunications
technologies. Advanced telecommunications can help PACE
providers access specialty care at a distance.
Strategy 4c: Build a coordinated network
between multiple rural health care providers interested in sponsoring
a PACE program and contractors necessary to operate a program.
By utilizing partnerships and contractual arrangements, rural PACE
programs can assemble the full complement of resources needed, even
in areas where those resources are spread out over great distances.
Challenge 5: Overcoming the Small Size and
Lower Capacity of Rural Health Care Providers
Because rural health care providers are typically
smaller and have fewer resources than their urban counterparts,
their ability to develop and maintain a PACE program will be limited.
Strategy 5a: Use alternative care sites
and other settings, such as senior housing facilities, assisted
living facilities and churches to deliver specific services.
By reducing reliance on the "one center" model of PACE
delivery and using existing facilities located near those seniors,
rural providers can more easily and more costeffectively reach seniors
spread out over greater distances. The use of such existing alternative
sites can reduce costs associated with building new facilities,
as well as transporting seniors and caregivers. It also may cut
down on the logistical difficulties of locating multiple services
in one center.
Strategy 5b: To the extent state regulations
allow, use community and family caregivers to minimize reliance
on PACE staff. By reducing reliance on traditional PACE
staff, rural programs can overcome workforce shortages and reduce
the need for staff travel.
Strategy 5c: Increase emphasis on home care
as an alternative to day center attendance. By using home
care, rural programs can reduce transportation costs, as well as
the need for multiple alternative sites and the costs associated
with them.
Strategy 5d: Utilize advanced telecommunications
technologies. By linking PACE providers with participants,
partnering medical personnel and other contractors, telecommunications
offer opportunities to access services at a distance, enhance coordination
of care and services, and reduce the costs of travel and transportation.
Strategy 5e: Build a coordinated network
between multiple rural health care providers interested in sponsoring
a PACE program and contractors necessary to operate a program.
By utilizing partnerships and contractual arrangements, rural PACE
programs can assemble the full complement of resources needed, even
in areas where those resources are spread out over great distances.
Strategies to Help Meet Multiple
Infrastructure Challenges
|
1
Face-to-face
Interaction
|
2
Transportation
|
3
Management
|
4
Workforce
Shortage
|
5
Provider
Capacity
|
Alternative Care Sites
|
X
|
X
|
|
|
X
|
Community Caregivers
|
X
|
X
|
|
X
|
X
|
Home Care
|
|
X
|
|
|
X
|
Telecommuni-cations
|
X
|
X
|
X
|
X
|
X
|
Coordinated
Network
|
|
X
|
X
|
X
|
X
|
Conclusion
While rural PACE programs face many challenges, many strategies
are available to help them overcome those challenges. Using the
strategies described above, along with others, rural PACE programs
can develop the infrastructure needed to succeed.
Issue 4: Using Information
Technologies
Advanced information technologies enable rural
health providers to meet some of the challenges inherent in a rural
setting: a patient base scattered over large areas; long distances
to specialty care; few resources with which to purchase diagnostic
and other equipment; and few providers. PACE providers serving rural
areas can apply these technologies to meet a range of requirements
for supporting their participants and integrating their services:
Monitoring participants' health status -
Telehealth applications offer a unique opportunity for a real-time
exchange of information between a participant in his/her home and
a care provider in another location. As a result, PACE interdisciplinary
teams retain the ability to make frequent adjustments to a participant's
care based on changes in health status. For example, smart toilets
can check a person's temperature, blood pressure and blood sugar,
and report that information to a PACE provider, who can use it to
support the safety and functioning of a person in their own home.
Gaining access to comprehensive services
- Through telemedicine networks, rural PACE programs can gain access
to specialist services located far away.
Providing health education - Telecommunications
can aid in the dissemination of information between centers, professionals,
participants and family members.
Supporting functional independence - Enabling
technologies can support frail elders to maintain their functional
independence. For example, technologies that enable mobility, communication,
meal preparation and eating can help elders to continue living safely
in a home setting.
Assembling and maintaining an interdisciplinary
team - Virtual interdisciplinary team meetings can be convened
via video-conferencing or teleconferencing. This would allow for
full participation of all team members no matter where they may
be located across the vast service areas of rural and frontier communities.
The ability to bring team members together on a daily basis to carry
out the requirements of a PACE interdisciplinary team would help
to ensure appropriate and thorough care management, planning and
needs assessment.
Developing staff and administering program
- Information technologies help not only the clinical aspects of
a PACE program, but also the non-clinical workings as well. A rural
or frontier PACE provider may find these technologies useful in
conducting in-service trainings, continuing medical education, administrative
meetings, and even the certification of Medicaid eligibility.
The ability of information technologies to serve
in these ways notwithstanding, there are challenges that must be
overcome. First, the use of information technologies to meet these
requirements must conform to the privacy protections specified by
the Health Insurance Portability and Accountability Act. In addition,
the use of information technologies faces a number of educational
and operational challenges. Fortunately, a range of strategies exist
to help rural PACE programs overcome these challenges.
Challenges and Strategies
Challenge 1: Creating the Willingness to Use
Information Technologies
The first order of business in using technologies
is to convince PACE participants and their family members that these
technologies are appropriate and reliable. It has been the experience
of many rural and frontier providers that participants are very
receptive to the new technologies and appreciate the benefits and
attention they offer. Notably, for those aged 65 and over, Internet
access has grown from just under 5 percent in 1998 to nearly 30
percent in 2002 (AARP, State of America 50+, 2004).
Strategy 1a: Offer training programs.
To build on this emerging interest and connectivity, rural PACE
providers can offer a voluntary training program to help participants
and their families use the technologies, such as a computer and
e-mail, appropriately and effectively.
Challenge 2: Building the Capacity to Use Information
Technologies
To reap the full benefits of information technologies,
rural PACE providers will need well-trained staff, adequate communications
infrastructure (sufficient Internet service, mobile phone networks
and other similar services), and appropriate equipment. Meeting
each of these requirements can be a challenge in rural areas.
Strategy 2a: Train health professionals
to use information technologies. Texas Tech University Health
Science Center is creating a geriatric telemedicine training program.
Rural PACE programs can link with universities and technical assistance
programs to create training programs that will help their health
care professionals develop and use telemedicine applications.
Strategy 2b: Partner with infrastructure
providers. The Northern California Telemedicine Network's
mission is to promote the use of telecommunications technologies
to improve and expand access to health care services in the region's
medically underserved communities. The network has brought together
various partners, one of which is a for-profit telecommunications
corporation, as a way to attract investments in their rural area.
At the same time, by participating in the network, private companies
develop access to new markets. Rural PACE providers can develop
and participate in partnerships to increase the technological capacity
of their service area.
Challenge 3: Obtaining Adequate Reimbursement
Information technologies are rarely used to their
full potential because of regulatory and legal uncertainties, such
as those pertaining to reimbursement rates.
Strategy 3a: Seek higher reimbursement rates.
Since PACE is a dual-capitated program, providers should seek to
understand and clarify their state's Medicaid reimbursement policies
for telemedicine and telehealth. The Telemedicine Reimbursement
Report lays out the telemedicine fee-for-service options that are
reimbursed on a state-by-state basis. A rural or frontier provider
may use the state telemedicine reimbursement laws to ensure that
the state's Medicaid PACE rate reflects appropriate costs associated
with delivering services using telehealth or telemedicine.
Information Technologies Resources
Several state, federal and philanthropic programs
offer valuable assistance in increasing the use of information technologies
in rural health care.
- The Centers for Medicare and Medicaid Services
maintains a list of states that reimburse for services provided
via telemedicine (www.cms.hhs.gov/states/telelist.asp).
- The U.S. Department of Health and Human Services'
Office for the Advancement of Telehealth serves as a leader in
telehealth, a focal point for the Department's telehealth activities,
and a vehicle for the wider implementation of advanced health
care technologies to provide services and education (http://telehealth.hrsa.gov/).
- Bioterrorism Funding - a federal fund that
supports upgrading public health infrastructure in order to respond
to a bioterrorism event in rural areas is available from the U.S.
Department of Health and Human Services. (http://www.hhs.gov/news/press/2003pres/20030509.html).
- The U.S. Department of Agriculture's Rural
Utility Service provides funding for distance learning and telemedicine
(http://www.usda.gov/rus/telecom/dlt/dlt.htm).
- The Universal Service Administrative Company
administers the Universal Service Fund, which provides communities
across the country with affordable telecommunication services
(http://www.universalservice.org/default.asp).
- The Robert Wood Johnson Foundation sponsored
the $10.3 million Health e-Technologies Initiative to support
systematic research in the evaluation of interactive eHealth applications
for health behavior change and chronic disease management (www.rwjf.org/cfp/etech).
- California's AT Network is dedicated to expanding
the accessibility of tools, resources and technology that will
help increase independence, improve personal productivity and
enhance the quality of life for all Californians (www.ATNet.org).
Conclusion
While rural PACE programs face many challenges, many strategies
are available to help them overcome those challenges. Using the
strategies described above, along with others, rural PACE programs
can access and use information technologies to build a successful
program.
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