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Setting the PACE for Rural Elder Care:
Challenges and Strategies

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).

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.

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

Alternative Care Sites
Community Caregivers
Home Care

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).

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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