Case exemplar for national policy leadership: Expanding Program of All-Inclusive Care for the Elderly (PACE)

Nursing’s leadership, public policy guidance, and advocacy deliver expansion possibilities to a proven model of care serving high-cost and high-need populations.

A new article “A Case Exemplar for National Policy Leadership: Expanding Program of All-Inclusive Care for the Elderly (PACE),” in the March 2016 Journal of Gerontology, chronicles the beginnings of PACE (Program of All-Inclusive Care for the Elderly) and outlines its rise to nationwide acceptance.  PACE is a viable and sustainable model of community-based long-term care that provides coordinated and comprehensive services with an interdisciplinary patient-centered team model that is paid for through Medicare, Medicaid, and other insurers.

Written by two nurse-leaders, Tara A. Cortes, PhD, RN, FAAN, and Eileen M. Sullivan-Marx, PhD, RN, FAAN, the article recognizes the advocates and leaders who have driven the model forward, describing the impact of nursing on the legislation and policy. 

It also highlights the nurses, such as Drs. Cortes and Sullivan-Marx, who for decades worked in various key political, policy, and clinical leadership positions behind the scenes and out on the front lines with community advocates, policy makers, and legislative groups to advocate and demonstrate the viability of the program.

“PACE provides coordinated acute, chronic care, and long-term services in an integrated seamless approach to healthcare by an interdisciplinary team across the care continuum,” said Drs. Cortes and Sullivan-Marx.  “This integrated and holistic patient-centered approach, made possible using a capitated financing payment model, results in greater longevity, better health outcomes, and a better quality of life for patients and their caregivers enrolled in the program.” 

Most importantly, PACE has demonstrated that it can keep individuals in the community and delay admission to institutions for an average of two years. 

“The program offers fully integrated Medicare and Medicaid services for dually eligible adults 55 and older who meet the criteria for nursing home level of care but are able to live in the community at the time they are enrolled,” said Drs. Cortes and Sullivan-Marx.

In November 2015, President Obama signed into law, an expansion of PACE.  The PACE Innovation Act (PIA) allows the Centers for Medicare & Medicaid Services (CMS) to develop pilot projects based on the successful PACE Model of Care.

“The PIA allows CMS to bring the PACE model to more populations -- including younger individuals, people with multiple chronic conditions and disabilities, seniors who do not yet meet the nursing home level of care standard, and others,” said Drs. Cortes and Sullivan-Marx.  “The goal being to improve the quality of health and life for adults 55 and younger and to reduce healthcare costs by maintaining individuals in, or returning them to, the community.”

In the article, the authors take the reader through a brief historical overview of the PACE program, beginning with its genesis in the 1970s in San Francisco’s Asian community, touching on legislative milestones along the way, which allowed the program to successfully expand nationally throughout the next four decades.

In its 2012 report to Congress, the Medicare payment Advisory Commission (MEDPAC), an independent Congressional agency established by the Balanced Budget Act of 1997 to advise the U.S. Congress on issues affecting the Medicare program, included recommendations to expand the PACE Model of Care. 

Support for the legislation was built over the next three years through discussions and “ownership” from groups that would be needed to promote this expansion program to Congress.  Organizations such as the National PACE Association, Alzheimer’s Association, March of Dimes, and some consumer advocacy groups became engaged as proponents of this expansion.

On November 5, 2015, with the stroke of the Presidential pen, PIA became law.   Specifically, PIA amends title XI of the Social Security Act to authorize the U.S. Department of Health and Human Services to waive applicable general and Medicaid requirements of PACE in section 11934 of the Social Security Act to conduct demonstration projects through the Center for Medicare and Medicaid Innovations (CMMI) that involve PACE. 

“The PACE Innovation Act also encourages CMS to allow operational flexibilities that would not only support adaptation of the PACE model for new populations but also promote PACE growth, efficiency, and innovation,” said Drs. Cortes and Sullivan-Marx.  “CMS now needs to use this broad authority to create PACE demonstration programs to establish the ability of this program to improve outcomes, enhance patient experience, and be cost-effective.  This program offers new opportunities to existing PACE providers and other for-profit as well as non-profit providers to explore new ways of providing services to high-need, high-cost populations.”

The article concludes with some visions for the PACE expansion, grounded in the tenants of providing access to the full continuum of preventative, primary, acute and long-term services, as well as short personal biographical vignettes highlighting a selection of nurse-leaders who paved the way for PACE, and now PIA, to become reality.

“In 2006, the American Academy of Nursing (AAN) recognized the PACE Program, Living Independently For Elders (LIFE) at the University of Pennsylvania School of Nursing (Penn Nursing), as an Edge Runner program that meets its criteria for innovation of a nursing program that drives better care, better quality, and lower cost,” said Antonia M. Villarruel, PhD, RN, FAAN, Penn Nursing Dean and Director, WHO Collaborating Center for Nursing and Midwifery Leadership.    “A dedicated team of nurse leaders, including Dr. Sullivan-Marx, was integral to the success of LIFE UPENN. Through their trailblazing efforts the program expanded and thrived. In fact, the team’s success was recognized as an exemplar for the Institute of Medicine (2010) Future of Nursing Report as a nurse-driven model.”

Nursing has been central to the PACE care model since its inception, and nursing leaders have been crucial in its development in both policy and operational expansion.  The leadership of both Drs. Sullivan-Marx and Cortes contributed to the Congressional action culminating in the signing of the PACE Innovation Act.

About the Authors

Dr. Cortes is Clinical Professor of Nursing, and Executive Director, The Hartford Institute for Geriatric Nursing at New York University College of Nursing.  Dr. Cortes is also 2013-2015 Health and Aging Policy Fellow, Medicare/Medicaid Coordination Office, Centers for Medicare & Medicaid Services, U.S. Department of Health and Human Services, Baltimore, Maryland.

Dr. Sullivan-Marx is Dean and Erline Perkins McGriff Professor, New York University College of Nursing.  In 2010, Sullivan-Marx became a Health and Aging Policy Fellow (HAPF), under the American Political Science Association’s Congressional Fellowship, for 2 years with CMS MMCO, an office established as part of the ACA. As a fellow, Sullivan-Marx, an expert in PACE programs, was appointed as a CMS Senior Advisor to update regulations, remove barriers to the growth of PACE models nationally, and assist Melanie Bella to advocate for PACE programs within CMS and Congress. 

About New York University College of Nursing

 NYU College of Nursing is a global leader in nursing education, research, and practice. It offers a Bachelor of Science in Nursing, a Master of Science and Post-Master’s Certificate Programs, a Doctor of Philosophy in Research Theory and Development, and a Doctor of Nursing Practice degree.  For more information, visit https://nursing.nyu.edu/

About the University of Pennsylvania

The University of Pennsylvania School of Nursing is one of the world’s leading schools of nursing and is ranked the #1 graduate nursing school in the United States by U.S. News & World Report. Penn Nursing is consistently among the nation’s top recipients of nursing research funding from the National Institutes of Health. Penn Nursing prepares nurse scientists and nurse leaders to meet the health needs of a global society through research, education, and practice. Follow Penn Nursing on:Facebook, Twitter, LinkedIn, Instagram & YouTube.