The
Rural PACE Assessment Instrument provides a framework for assessing
a prospective rural PACE program and the relative strengths and
weaknesses of its sponsoring organization. The instrument captures
the prospective rural PACE sponsor's understanding of the need for
PACE services and its ability to successfully position those services
in the community. The instrument also includes an assessment of
state support for a PACE program. Using these factors, the instrument
provides for a rating of strength in each key area.
Objective and Overview
The Rural PACE Assessment Instrument is designed
to serve a prospective sponsor as it describes and analyzes the
factors shaping its efforts to develop PACE. The instrument can
help to identify areas of challenge and opportunity, as well as
where additional information is needed. A prospective rural PACE
program's consideration of these areas will determine what next
steps will be most appropriate. The instrument will serve a prospective
rural PACE provider best if it is completed based on the most accurate
information available.
The Rural PACE Assessment Instrument consists
of four sections:
Section 1: Proposed Rural PACE Program and
Service Area Description
This section describes the sponsoring organization, its community,
proposed service area and proposed service population.
Section 2: Critical Factors
This section provides for detailed assessment of four critical factors,
to be considered in sequence, affecting the development of a new
PACE program:
Critical Factor 1: Service Area's Potential Demand for Services
Critical Factor 2: Community Relationships and Existing Services
Critical Factor 3: State Environment
Critical Factor 4: Organizational Capacity and Commitment
Section 3: Self-Rating
This section contains self-rating scales for each of the critical
factors and the key areas within each factor.
Section 4: Next Steps
The final section addresses the next steps the organization will
take based on the results of the assessment.
Interpreting Assessment Results
Rural PACE programs that are well integrated into
the community have the potential to serve a substantial proportion
of eligible, rural elders within their service area. A provider's
ability to realize this potential will reflect the external and
internal factors included in the instrument.
Externally, the provider will need to consider
its relationship with: state aging and medical assistance agencies;
local health, housing and aging service providers; and community
organizations.
- Do these relationships indicate that a new
PACE program would have external support?
- Would a new organization receive sufficient
enrollment referrals?
- Could a new organization provide or contract
for all necessary PACE services?
- Will state regulators support the program's
start-up?
Internally, the provider's mission, financial
strength, organizational structure, ability to partner collaboratively,
and assignment of key staff will be significant factors in its potential
to develop a rural PACE program.
- Does the sponsor's mission support the PACE
program's focus on frail elders?
- What are the financial costs and potential
sources of funds?
- Are partners needed?
- What staffing plan would need to be put in
place?
External and internal strengths in some areas
may compensate for weaknesses in one or more other areas. Consequently,
a prospective PACE sponsoring organization will need to apply its
own knowledge of the importance of these factors based on its specific
situation.
Section 1
Proposed Rural PACE Program and Service Area Description
General Information
- In one or two paragraphs, describe your organization,
the services it provides, clients it serves, and the project team
that will be responsible for assessing the potential for rural
PACE.
- Why does your organization want to do PACE?
- In one or two paragraphs, describe your community.
Specifically, address how where you provide service affects how
you provide services.
Proposed Service Area Description
Summarize your service area in terms of its:
- State(s)
- Counties
- Zip Codes
- Geographic Size
- Greatest distance from end to end
- Radius from proposed service area to center
- Road System and Impact on Transportation
- Driving Times from Key Service Areas (e.g.,
hospital, potential service delivery sites)
- Topography Factors (mountains, rivers, etc.)
- Seasonal Factors (e.g., snow, heat)
- Population Centers - General
- Population Centers - Elderly Persons
Note: Consider developing and attaching a map
of the proposed service area with key location of health and human
services providers, transportation routes, and transportation times
identified.
Rurality of Service Area
For your proposed service area:
- What is the USDA rural-urban continuum code?
- What is the USDA urban influences code?
- What is the USDA rural-urban commuting code?
There are many unique challenges in assessing
community needs in a rural area as opposed to an urban community.
One challenge is attempting to characterize the rurality of each
community. It is not adequate just to look at the population of
a service area. An area's population density, its distance from
an urban area and the economic relationships it has with other communities
are some of the other factors that must be considered.
Unfortunately, there is not general agreement
about how to measure rurality. Different government agencies use
different methodologies based on their needs. However, among the
various methodologies that exist, the rural continuum developed
by the US Department of Agriculture's Economic Research Service
for counties is helpful (http://www.ers.usda.gov/Topics/View.asp).
The agency has developed six rural classifications along its continuum
and three urban classifications. One note of caution: the methodology
changed in 2003, so the backward compatibility of the data with
past years is not completely reliable.
The Economic Research Service produces a number
of reports that may be helpful. For more information on measuring
rurality, the agency's home page on measuring rurality is: http://www.ers.usda.gov/data/ruralurbancontinuumcodes/.
The following three reports also may be helpful:
Service Area Disease Prevalence
In order to estimate the value of the PACE program
to the service area, and begin planning for composition of the PACE
program, it is helpful to identify the most prevalent disease in
the proposed service area. Effective approaches to manage these
diseases might inform the potential PACE sponsor about issues such
as risk management, staffing patterns and contracts with other providers.
It also might be helpful to be aware of diseases associated with
special state or federal reimbursement opportunities, like black
lung disease in certain coal mining areas. These considerations
may be particularly important in ensuring an appropriate rate is
set for PACE in the service area.
- What are the most prevalent diseases in your
service area?
- Are there diseases in your area associated
with special state or federal reimbursement programs (e.g., black
lung)?
Additional Populations
As providers in a service area consider developing the necessary
infrastructure to support a PACE program, their capacity to provide
care and services to other underserved populations also may be expanded.
While PACE programs are limited to those aged
55 and older who need a nursing home level of care, organizations
sponsoring a PACE program may wish to build on the expertise required
for PACE to serve new populations and offer new services.
For example, an organization developing a PACE
program may be able to integrate services for the younger disabled
population, children with special health care needs, people with
AIDS, or the chronically ill who require care management services.
While these services would not be reimbursed as PACE services, they
may help to spread some of the fixed costs associated with a PACE
program and generate some economies of scale.
- Does the proposed PACE program's development
call for the development of related services as part of its start-up?
- Would the organization seek to build on an
operational PACE program in order to offer related services to
an expanded population?
Section 2
Critical Factors
This section presents the critical factors that
will shape a prospective PACE program's likelihood of success.
Critical Factor 1: Service Area's Potential
Demand for Services
To estimate a service area's potential demand for services, the
instrument looks at the number of people aged 65 and older, their
clinical status and income status. Attachment A presents a detailed
approach to assessing potential demand for services using Bureau
of the Census data for the population in the rural PACE program's
planned service area. This approach is described below. Additional
state and local data sources also may be useful in estimating demand.
Some examples of these sources are identified in the last section.
Key Area: Demographic Need
The demographic needs assessment used year 2000
Bureau of the Census data to estimate the potential population a
PACE program could serve. This assessment uses the following factors:
- Aged 65 and older: While eligibility for PACE
services begins at age 55, the available Bureau of the Census
data is grouped for those aged 65 and older. In this sense the
estimate of the potential population a PACE program would serve
is conservative, since it does not include those aged 55-64 that
could be served. Based on current PACE program experience, the
substantial majority of PACE enrollees are over the age of 65,
with an average age at enrollment of 80.
- Clinical Status: PACE enrollees must meet their
state's clinical criteria for needing a nursing home level of
care. To approximate state criteria, the instrument looks at the
population's level of disability using three measures, ranging
from least to most conservative:
- Inability to go outside the home;
- Self-care; and
- Disability in two or more activities of daily
living, one of which is self-care.
- Income: Currently 9 in 10 PACE enrollees are
financially eligible to receive Medicaid. While
- Medicaid financial eligibility consists of
income and asset level tests, the instrument looks at income only.
Each state's income level for Medicaid eligibility may be different.
Most states set the level equal to 300% of Social Security Income.
Others specify income levels based on unique formulations. It
is not necessary to be financially eligible for Medicaid to enroll
in PACE. The instrument presents the number of people both with
and without Medicaid financial eligibility that might seek to
use PACE services.
To assist a prospective rural PACE program in
considering the results of the demographic assessment, two additional
sections present the estimated number of potential PACE participants
in terms of:
- The market penetration rate needed to achieve
a specified range of enrollment levels; and
- The estimated enrollment that would be achieved
based on a specified range of market penetration rates.
1. What does the demographic needs assessment
identify as the potential population that could be served by PACE
in your service area based on age and clinical condition?
2. What is the potential population that could
be served by PACE based on age, clinical condition and income level
that would indicate Medicaid eligibility?
Supplemental Data Sources
Some potential additional sources of information
might be available that can help an organization understand its
market. These include:
- State projection of population growth. What
projections does the state's eligibility agency use?
- Local health care councils (looks at health
care service patterns in primary service areas - PSAs).
- State information on mentally retarded/developmentally
disabled (MRDD) population 55-64 years old.
Critical Factor 2: Community Relationships
and Existing Services
The development of a PACE program requires an
understanding of existing community relationships and services.
This understanding lays the foundation for adequate referral networks
that will help the program build, census, contracted services to
meet PACE participant needs, and public support for the program.
Assessing community relationships and existing services is an opportunity
to gather information about the resources in the proposed service
area that may be used to implement a PACE program. In addition,
the assessment is an opportunity to educate other stakeholders and/or
referral sources in the service area about the PACE model so that
they can be potential partners.
A. Key Area: Access To Long Term Care Services
1. How do people currently access long term care
services (i.e., nursing home, home and community
based services, adult day care or home care)?
2. Describe your community's referral processes.
3. What is the process for Medicaid clinical eligibility
determination?
4. What is the process for Medicaid financial
eligibility determination?
5. Describe the relationship of the proposed internal
and external referral sources to the proposed PACE sponsor.
Referral Source |
Relationship to Sponsor |
Expected Impact on Enrollment |
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6. How will these relationships impact enrollment
in PACE?
7. Does your state have a single-entry point for
determining clinical and financial eligibility for state-funded
services?
8. If yes, does the single-entry point also provide
direct services?
B. Key Area: Existing Partnerships
Contractual relationships and other partnerships
between providers in the community should be noted and understood.
They can provide a foundation for possible partnerships and contractual
relationships that may be necessary to provide the broad range of
care and services required under PACE. It also is helpful to note
what organizations have not worked together in the past or may view
each other as potential competitors.
1. Describe any strategic alliances or partnerships
between health care, housing or aging service providers in your
area.
2. Describe any organizations that are not willing to work with
other organizations.
C. Key Area: Existing Staffing
1. Nurse Aide Staffing
For PACE, as with many forms of long term care,
an adequate number of nurse aides is key to providing effective
care.
- Do other health care providers in the proposed
service area have difficulty or success in attracting and retaining
nurse aide staff?
- Are other employment competitors present in
the proposed service area that may affect nurse aide recruitment?
- Are there numbers of recently unemployed persons
who might be interested in becoming trained as nurse aides?
2. Nurse Staffing
Recruiting nursing staff members is essential
to providing home care, PACE center services, clinical assessment
and care planning in the PACE model.
- Do other health care providers in the proposed
service area have difficulty or success in attracting and retaining
nursing staff?
- Are other employment competitors present in
the proposed service area that may affect nursing recruitment?
3. Primary Care, Geriatrics and Specialists
Physician relationships will affect the
program in terms of the role physicians play as a referral source
and the relationship of the physicians to the PACE program's interdisciplinary
team.
- Will the PACE program have its own primary
care physician or does it plan to incorporate community physicians
(which will require a CMS waiver) into the program?
- Which physicians in the proposed service area
currently are providing care for Medicare and Medicaid patients?
(Note: These physicians might be the most willing to participate
with PACE. They also may be the most resistant to PACE if they
will no longer be able to be paid for treating their existing
Medicare and Medicaid patients.)
- Which primary care providers, particularly
if community physicians are going to play a large role in the
delivery of PACE services, will be looked to for expertise in
geriatrics?
4. Informal Caregiving
One key to the success of the PACE model of care
is the extent that it can support family and other informal caregivers
to provide care and services in the community. It is important to
understand, to the extent possible, the amount of informal caregiving
that is present in the community. The Alzheimer's Association, home
health agencies and hospitals, as well as a state's department of
human services, area agencies on aging or office of adult services,
may be able to help quantify to what extent informal caregiving
is taking place in the proposed service area.
- To whom would the area agency on aging refer
an interested family member for more information?
- Does the state allow programs that pay family
members as caregivers? (This could be both a possible source of
caregiving staff and potential competition for potential PACE
enrollees.)
D. Key Area: Telemedicine/Technology
Telemedicine and new technologies increasingly
are being utilized in rural areas to overcome some of the challenges
associated with greater distances and the common shortage of health
care professionals.
Telemedicine can be used for expert consultation, to enhance delivery
in clinic settings, and to deliver care and services in the home.
Some examples of the successful use of telemedicine
include: reading X-rays, radiology, ultrasounds, telepharmacy (when
the pharmacist is away), speech therapy, wound care, dermatology,
psychology, diabetes monitoring, chronic disease management, case
management, case team coordination, continuing education of health
care staff, and potential administrative functions such as billing
and coding. For more information, refer to NPA's "Technology
in Rural PACE" issue brief.
1. What telemedicine/technology programs exist
or could be developed in your service area?
2. Can specialist care be provided using existing
telemedicine/technology programs to offset shortages of these providers
in your service area?
E. Key Area: Related Long Term Care Services
Existing health care and aging services providers
should be identified in the proposed service area.
1. Publicly Funded Long Term Care Services: What
long term care services that are publicly funded (i.e., Medicaid
or state-only funded) are available to serve your target population?
- adult day care
- home care
- case management
- personal care
- assisted living
- consumer-directed care
- home and community based waivers (see #3 below)
- skilled nursing facility
- meals assistance
- transportation
- other: (__________________________________)
2. Home and Community Based Programs: Using Attachment
B, list the home and community based waiver programs in your proposed
service area. Please describe these programs.
3. Home and Community Based Long Term Care Providers:
Using Attachment C, list the home and community based long term
care providers in your proposed service area. Please describe these
providers.
4. Nursing Facilities: Describe the nursing facilities
that serve your market.
Provider Name |
# of beds |
Enrollment/
Occupancy
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Waiting List? |
Cost |
Comment (re: quality,
reputation, potential for partnership)
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5. Assisted Living: Describe the assisted living
facilities that serve your market.
Provider Name |
# of beds |
Enrollment/
Occupancy
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Waiting List? |
Cost |
Comment (re: quality,
reputation, potential for partnership)
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6. Housing: Describe the low income and affordable
housing providers in your service area. What proportion of the residents
is elderly? Are supportive services offered on site (specify what
services)?
Provider Type |
Capacity-Number of Housing Units |
Proportion of Residents that are elderly
- estimated |
Services Provided |
Comment |
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7. Primary, Acute and Specialist Care: Describe
the primary, acute and specialist care providers in your service
area, including any rural hospitals, federally qualified health
centers or physician groups/practices that will be important to
consider.
Provider Type |
Services Provided |
Comment |
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Critical Factor 3: State Environment
The PACE provider agreement that allows providers
to enroll participants and receive PACE capitated payments is a
three-way agreement between the state, the provider and the Centers
for Medicare and Medicaid Services (CMS). It is important that providers
work with their states to ensure, to the greatest extent possible,
that they are ready to support a PACE program. (NPA recently has
developed many technical assistance resources to aid states.)
A. Key Area: State Long Term Care Programs
1. What is your sense of your state's commitment
to home and community based services relative to institutional care?
2. How is PACE consistent or inconsistent with
the state's long term care goals?
3. Does the state have existing innovative programs
that serve older persons with chronic care needs?
4. Does the state currently have a PACE program
or one under development elsewhere?
5. Has the state ever explored PACE before? If
so, with what result and why?
6. What state agencies might need to be involved
with supporting PACE (e.g., health, licensing, Medicaid, budget,
aging, insurance, housing, governor's office staff).
B. Key Area: State Financing
1. Does the state view money spent on PACE enrollees
as a shift from another expenditure it otherwise would have to make
or as new money it has to find? Do different departments view this
question differently?
2. Does the state have resources it is ready to
commit to funding new PACE services?
C. Key Area: Medicaid Eligibility
1. What state agency determines eligibility? Is
it supportive?
2. What are the state's requirements related to
financial eligibility/clinical eligibility? Is one of these areas
particularly stringent compared with other states?
3. Will PACE be an easy fit (from the state's
perspective) with other programs requiring eligibility determination?
4. How long does eligibility determination usually
take?
Provider Type Services Provided Comment
Critical Factor 4: Organizational Capacity
and Commitment
How will your organization sustain the overall
development of a PACE program? Who will lead this effort? Will a
team be created to support planning and development of the program?
From where will you recruit members of your team? With what services
offered through PACE or care management strategies used by PACE
does your organization have experience? Beyond service delivery
and care management, consider what administrative and financial
infrastructure will need to be developed.
A. Project Resources and Related Experience
1. Key Area: Leadership and Key Staff
a. Who is the contact person for the PACE project?
b. Is there a potential clinical leader (i.e.,
either nurse or physician) who can provide support for the program?
Who is this? What is his/her background and interest in rural PACE?
c. In exploring the development of a PACE program,
who has agreed to serve on the leadership team?
Where will the team be within your organizational structure?
d. To what extent is your organization's chief
financial officer aware of and supportive of PACE?
e. What experience and background will team members
contribute to the team's effectiveness in developing a prospective
PACE organization?
Note: In large organizations, PACE programs succeed
when placed in a strong relationship with key administrative staff
within the organization. Having direct links to key decision makers
within the organization strengthens the program's ability to respond
quickly to issues that occur during start-up phases of program development.
2. Key Area: Experience
In which of the following does the proposed organization,
including all partners, have experience?
a. direct provision of acute care
b. direct provision of long term care
c. transportation
d. providing community based care (specify: ______________________________)
e. senior housing
f. serving dual-eligible, frail population
g. use of interdisciplinary teams
h. managing risk (specify: _____________________________)
i. developing service networks
j. medical care
k. adult day care
l. home care
m. telemedicine
n. care management
o. other (specify: __________________________________________)
3. Key Area: Resources and Timelines
a. Can the organization devote resources sufficient
to develop a plan for the implementation of a PACE program?
b. What considerations regarding the sustainability
of the program have you identified?
c. What potential sources of capital and start-up
funding are available (e.g. foundations, state funds)?
How will these be accessed?
B. Organizational Support
1. Key Area: Priorities and Mission
a. What is the organization's mission?
b. How does the organization's mission relate
to your community's goals and priorities?
c. What other organizational priorities currently
are being evaluated?
2. Key Area: Strategic Fit
a. Has the organization considered how PACE fits
into its strategic long range plan? If yes, describe the strategic
plan as it relates to PACE.
b. Is the organization interested in providing
a full range of integrated services or is its focus on specializing
in a particular health service/setting?
Section 3
Self-Rating
Rate your organization's strength with regard
to each of the key areas on a scale of one to five, with five being
the most favorable. In addition, rate the completeness of the information
for each key area, with five being the most complete.
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Strength |
Completeness |
CF1, A |
Demographic Need |
1 2 3 4 5 |
1 2 3 4 5 |
CF2, A |
Access to LTC Services |
1 2 3 4 5 |
1 2 3 4 5 |
CF2, B |
Existing Partnerships |
1 2 3 4 5 |
1 2 3 4 5 |
CF2, C |
Existing Staffing |
1 2 3 4 5 |
1 2 3 4 5 |
CF2, D |
Telemedicine/Technology |
1 2 3 4 5 |
1 2 3 4 5 |
CF2, E |
Related LTC Services |
1 2 3 4 5 |
1 2 3 4 5 |
CF3, A |
State LTC Programs |
1 2 3 4 5 |
1 2 3 4 5 |
CF3, B |
State Financing |
1 2 3 4 5 |
1 2 3 4 5 |
CF3, C |
Medicaid Eligibility |
1 2 3 4 5 |
1 2 3 4 5 |
CF4, A.1 |
Leadership and Key Staff |
1 2 3 4 5 |
1 2 3 4 5 |
CF4, A.2 |
Experience |
1 2 3 4 5 |
1 2 3 4 5 |
CF4, A.3 |
Resources and Timeline |
1 2 3 4 5 |
1 2 3 4 5 |
CF4, B.1 |
Priorities and Mission |
1 2 3 4 5 |
1 2 3 4 5 |
CF4, B.2 |
Strategic Fit |
1 2 3 4 5 |
1 2 3 4 5 |
Total Score |
(maximum of 70 possible) |
________ |
________ |
Highest Scoring Key Area(s) for Strength:
1. ____________________________________________________________________
2. ____________________________________________________________________
3. ____________________________________________________________________
Lowest Scoring Key Area(s) for Strength:
1. ____________________________________________________________________
2. ____________________________________________________________________
3. ____________________________________________________________________
Areas Requiring More Information Before Proceeding:
1. ____________________________________________________________________
2. ____________________________________________________________________
3. ____________________________________________________________________
Section 4
Next Steps
A. Discuss the results of the self-assessment
with your PACE development team.
B. Contact the National PACE Association (at ruralpace@npaonline.org
or 703/535-1517) to request a desk review of your completed assessment
instrument.
Attachment A: Potential PACE Population
Estimate
The following section presents a detailed explanation
of the sources used from the Senior Life Report in the calculation
of the factors and the final estimate. Apply these calculations
to the Estimated Market of Potential PACE Participants Summary Demographic
Report to generate the answers for Critical Factor 1: Service Area's
Potential Demand for Services, Key Area: Demographic Need.
1. Total Population, 2003 (estimated from 2000)
This number comes directly from the Senior Life Report under the
"Population by Age" section, in the "Total Population"
row. It includes all ages.
2. Total Population 65+
This number comes directly from the Senior Life Report under the
"Population by Age" section, "Total Population"
category in the "Age 65 and over" row.
3. Total Population 75+
This number is a sum of the age categories Age 75 and older (75
to 79, 80 to 84, 85+) under the "Population by Age" section,
"Total Population" category.
4. Total Civilian Noninstitutionalized Persons
65+
This number is the sum of Males and Females Age 65 and older (65
to 74, 75+) under the "Mobility and Disability Civilian Noninstitutionalized
Persons Age 16 and over" section, "Disability by Sex and
Age" category, "Male" row and "Female"
row.
5. Total Civilian Noninstitutionalized Persons
65+ with a disability or combination of disabilties (Self-Care Disability
and Go-Outside-Home Disability)
These numbers come directly from the Senior Life Report under the
"Mobility and Disability Civilian Noninstitutionalized Persons
Age 16 and over" section, "Total Disability" category.
6. % of Civilian Noninstitutionalized Persons
65+ with a disability or combination of disabilities indicating
clinical eligibility for PACE
These numbers are the product of the number of total civilian noninstitutionalized
persons 65+ with a disability (#5) divided by total civilian noninstitutionalized
persons 65+ (#4).
7. Estimated population 65+ that would be clinically
eligible for PACE
This applies the disability rates calculated for the noninstitutionalized
population aged 65+ to the total number of people 65+, both institutionalized
and noninstitutionalized, from number 2 above.
8. Total 65+ Households, 2003 (estimated from
2000)
This number is a sum of the total householders for each of the categories
"Householder Age 65-74" and "Householder Age 75 and
over" under the "Household Income by Age of Householder"
section.
9. 65+ Households with income < $20,000
This number is a sum of the age categories Householder Age 65 and
older that are less than or equal to an income of $18,000. This
can be done simply for each age category less than $15,000. For
the other income range of $15,000 - $24,999, 50% of the number of
households is used as an estimate of the number of households with
an income between $15,000 and $20,000. This is done because we are
estimating the number of those households that fall within the Medicaid
financial eligibility limit and $20,000 is approximately one-half
of the way between $15,000 and $24,999 for income.
10. % of 65+ Households with income < $20,000
This number is the product of the number of 65+ households with
income less than $20,000 (#9) divided by the total 65+ households
(#8).
11. Estimated population 65+ that would be financially
eligible for Medicaid coverage of PACE (those w/ income <$20,000)
This number is the product of % of 65+ households with income less
than $20,000 (#10) multiplied by the total population 65+ (#2).
12. Estimated clinically eligible population for
whom Medicaid would pay for PACE
This number is the product of the estimated population 65+ with
income less than $20,000 (#11) multiplied by the percentage of people
aged 65 and older who would be clinically eligible for PACE (#6).
Attachment B: Home and Community
Based Waiver Programs in Your Service Area
Program Name |
Target Population |
Services Provided |
Financial Eligibility |
Limits on Number of People the Program Serves |
Waiting List for Program - If yes, how many
people? |
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Attachment C: Home and Community
Based Long Term Care Providers
Provider Type/Name |
Range of Services
Provided
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Quality and Reputation |
Referral Potential |
Rural PACE Partner Potential |
Adult Day Care |
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Personal Care |
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Home Care |
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Hospice |
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Other |
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