Research
The PACE model of care has been both a subject of research and a setting for research. This section provides information on research that has been published about PACE, the work of the NPA Clinical & Operational Data Analysis Committee, and an evaluation of PACE as a cost-effective model of care.
Key Research Findings
Since the first program began 30 years ago, PACE has been the subject of more than 100 health care articles. Researchers have examined a range of factors to determine whether the community-based, comprehensive and accountable care offered by PACE providers delivers quality care, improved health and value for the health care system.
This chart summarizes key research findings demonstrating PACE effectiveness in delivering gold standard care for older adults and the ways that the approach can be a model for others looking to improve the health care system.
Quality CarePACE treats the whole person, not just a combination of medical conditions. |
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Key Findings |
Supporting Research |
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PACE is effective and efficient in treating individuals with multiple and complex health care needs. |
PACE was one of three chronic care models identified that include processes that improve the effectiveness and efficiency of complex primary care. There are four processes present in the most successful models of primary care for community-based older adults who have multiple chronic conditions, including PACE: development of a comprehensive patient assessment that includes a complete review of all medical, psychosocial, lifestyle and values issues; creation and implementation of an evidence-based plan of care that addresses all of the patient's health needs; communication and coordination with all who provide care for the patient; and promotion of the patient's (and their family caregiver's) engagement in their own health care. Boult, C., Wieland, G.D. (2010). Comprehensive primary care for older patients with multiple chronic conditions: "Nobody rushes you through.” JAMA, 304 (17): 1937-43. |
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Caregivers and participants rate PACE high in satisfaction. |
The findings document a comparatively low annual rate of disenrollment from PACE (7 percent), suggesting that enrollees are quite satisfied with the care they receive. There is no increase in disenrollment risk by age, functional or cognitive impairment, Medicaid eligibility or diagnoses. Temkin-Greener, H., Bajorska, A., Mukamel, D.B. (2006). Disenrollment from an acute/long-term managed care program (PACE). Medical Care, 44 (1): 31-38.
PACE participant satisfaction levels and family member/caregiver satisfaction levels are high (96.9 percent to 100 percent) among enrollees of PACE organizations in Tennessee. Damons, J. (2001). Program of All-Inclusive Care for the Elderly (PACE) Year 2 Overview. Long-Term Care, Bureau of TennCare, Tennessee. |
Improved HealthPACE emphasizes timely preventive primary care over specialty and institutional care. |
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Key Findings |
Supporting Research |
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PACE participants report they are healthier, happier and more independent than counterparts in other care settings. |
A U.S. Department of Health and Human Services study found higher quality of care and better outcomes among PACE participants compared to home and community-based service (HCBS) clients. PACE participants reported better self‐rated health status; better preventive care with respect to hearing and vision screenings, flu shots and pneumococcal vaccines; fewer unmet needs, such as mobility and dressing; less pain interfering with normal daily functioning; less likelihood of depression; and better management of health care. Both PACE participants and HCBS clients reported high satisfaction with their quality of life and the quality of care they received. Leavitt, M. (2009). Interim report to Congress. The quality and cost of the Program of All-Inclusive Care for the Elderly. |
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PACE participants live longer than enrollees in a home- and community- based waiver program. |
This South Carolina-specific study examined long-term survival rates of participants in PACE and an aged and disabled waiver program over a five-year period. Despite being older and more cognitively and functionally impaired than those in an aged and disabled waiver program, PACE participants had a lower long-term mortality rate. When stratifying for mortality risk, “PACE participants had a substantial long-term survival advantage compared with aged and disabled waiver clients into the fifth year of follow-up.” The benefit was most apparent in the moderate- to high-risk admissions, highlighting the importance of an integrated, team-managed medical home for older, more disabled participants, such as those in a PACE program. Wieland, D., Boland, R., Baskins, J., Kinosian, B. (2010). Five-year survival in a Program of All-Inclusive Care for the Elderly compared with alternative institutional and home- and community-based care. The Journals of Gerontology: Series A Biological Sciences and Medical Sciences, 65 (7): 721-26. |
Cost-EffectiveThe focus on prevention and wellness means avoiding unnecessary care and the costs that go along with it. |
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Key Findings |
Supporting Research |
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PACE reduces the need for costly, long-term nursing home care. |
The study found that “despite the fact that 100 percent of the PACE participants were nursing home-certifiable, the risk of being admitted to a nursing home long-term following enrollment from the community is low.” The risk of admission to nursing homes for 30 days or longer was 14.9 percent within three years. Based on this study of 12 PACE sites, fewer than 20 percent of participants who died spent 30 days or more in a nursing home prior to death. Friedman, S., Steinwachs, D., Rathouz, P., Burton. L., Mukamel, D. (2005). Characteristics predicting nursing home admission in the Program of All-Inclusive Care for Elderly people. The Gerontologist, 45 (2): 157-66. |
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PACE prevents and/or significantly reduces preventable hospitalizations. |
In this Texas-specific study, the analysis concluded that despite the number and severity of participant medical conditions, PACE saves Texas about 14 percent compared to statewide costs of regular nursing home and medical care for the frail elderly. While PACE cares for a more frail population than Medicare in general, PACE enrollees had fewer hospital admissions and shorter hospital stays, thus successfully preventing avoidable conditions that could require or lengthen hospitalization. Rylander, C. (2000). Recommendation of the Texas Comptroller: Chapter 8: Health and Human Services, Expand the Use of an Effective Long-Term Care Program. Texas Comptroller of Public Accounts, Austin, TX.
PACE provides a 17 percent cost savings relative to the TennCare managed care organization/behavioral health organization nursing facility system. Inpatient hospitalization rates are low, averaging 1,140 days per 1,000 and a 3.1-day average length of stay. An average of 8 percent of participants received care in a nursing home. Damons, J. (2001). Program of All-Inclusive Care for the Elderly (PACE) Year 2 Overview. Long-Term Care, Bureau of TennCare, Tennessee.
PACE enrollees had fewer hospital admissions, preventable hospital admissions, hospital days, emergency room visits and preventable emergency room visits than a comparable population enrolled in the Wisconsin Partnership Program. Kane, R. L., Homyak, P., Bershadsky, B., Flood, S. (2006). Variations on a theme called PACE. Journal of Gerontology Series A, 61 (7): 689-93.
The Massachusetts Division of Health Care Finance and Policy (DHCFP) evaluated the effectiveness of the PACE program in keeping its enrollees well and out of a hospital. PACE was compared to a group of older adults who, like PACE program participants, were nursing home-eligible but receiving care in a home or community rather than institutional setting, and a sample of nursing home residents. The analysis found that PACE inpatient days, average length of stay, and outpatient emergency department visit rates were lower than the nursing home group. PACE also showed lower rates of inpatient discharges, days, and emergency department visits than the waiver group. Division of Health Care Finance and Policy, Executive Office of Elder Affairs. (2005). PACE Evaluation Summary.
A New York City-specific study compared hospital and skilled nursing facility utilization between PACE and a Medicaid-sponsored, managed long-term care plan. PACE participants had fewer hospitalizations than the Medicaid plan enrollees. |
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Medicaid plan members were more likely to be admitted to a hospital and experienced longer stays. Nadash, P. (2004). Two models of managed long-term care: Comparing PACE with a Medicaid-only plan. Gerontologist, 44 (5): 644-54. |
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PACE produces Medicare savings. |
Total Medicare and Medicaid capitation payments are generally comparable to estimates of projected Medicare and Medicaid fee-for-service (FFS) expenditures for PACE enrollees in the year following enrollment. For this period, the study estimates Medicare capitation rates are 42 percent to 46 percent lower than estimates of fee-for-service expenditures, while Medicaid capitation rates are higher than estimated fee-for-service costs. The analysis, however, does not provide an overall assessment of the cost-effectiveness of PACE to states. This would require the cost experience of comparable populations followed for a longer time period – at a minimum of several years post enrollment. White, A., Abel, Y., Kidder, D. (2000). Evaluation of the Program of All-Inclusive Care for the Elderly Demonstration: A comparison of the PACE capitation rates to projected costs in the first year of enrollment. Abt Associates, Contract No. 5001.
Medicare costs for PACE and a comparative group were analyzed for a 60-month study period and found to be similar, suggesting Medicare capitation rates for PACE were set appropriately. For Medicaid, PACE and the comparison group costs were followed for only two years, and the secretary of Health and Human Services acknowledged that the abbreviated study period did not include expenditures of institutional and end-of-life care normally incurred by Medicaid later in a person’s care trajectory. Leavitt, M. (2009). Interim report to Congress. The quality and cost of the Program of All-Inclusive Care for the Elderly.1 |
1. This is the most recent government-sponsored study to evaluate objectively the quality and cost of PACE. A complete and current PACE study that examines savings to Medicaid and compares costs over a longer time period is needed.
If you know of PACE studies that are not referenced here, contact info@npaonline.org.