PACE: Effective Care Coordination for Dual Eligibles

By Maureen Hewitt

Care coordination, the use of an interdisciplinary health team to coordinate and provide patient care, sounds simple enough. So why does it remain so difficult to implement?

Technology has removed some of the borders found in medical care, making communication and data sharing faster and easier, which helps care coordination implementation. Nevertheless, bringing together care, communications and data remains a challenge and an ongoing goal for many healthcare organizations.

Older adults have the answer

Eldercare providers are always looking for better, more efficient ways to serve this population, which is often medically frail. The primary issue: many dual eligibles receive uncoordinated and expensive care through a fee-for-service model. These patients are kept “in ‘treatment silos’ connecting with one provider at a time—even when they have five doctors—and getting one prescription at a time—even when they take 15 different pills a day,” according to a 2009 report published by the Center for Health Care Strategies (CHCS).

Maureen Hewitt, InnovAge President and CEO
Maureen Hewitt, InnovAge President and CEO

Those in healthcare have discussed the necessity of care coordination for years to reduce or eliminate many of the issues associated with fragmented care as described by CHCS. Receiving care at multiple facilities and having medical data added to numerous electronic medical records that don’t “talk” is as much a concern for healthcare providers as it is for dual-eligible patients.

Bringing care under one roof has the benefit of eliminating the challenges inherent in siloed care. And supplementing it with a highly-proficient healthcare team has the benefit of mixing together the care and people necessary to improve the health and wellness of dual eligibles.

Care coordination demonstrations

In 2015, several states participated in demonstration projects designed to explore the usefulness of care coordination for dual-eligible beneficiaries. Eligible for Medicare and Medicaid, dual eligibles qualify for both government healthcare programs. There were nearly 10 million dual eligibles as of 2011, according to The Henry J. Kaiser Family Foundation. And while Medicaid is designed to assist low-income families, the program also helps older adults. Medicare focuses on older adults.

“Care coordination,” as a 2015 RTI International report funded by Centers for Medicare and Medicaid Services (CMS) aptly states, “generally include(s) an assessment of an individual’s medical, physical, and other social support needs, development of a personalized plan of care/action plan, monitoring and clinical management of people with complex care needs, and helping beneficiaries locate and obtain needed services.”

Care coordination should be implemented by an interdisciplinary team, including physicians, nurses, social workers and other healthcare professionals who ensure the continuity of competent and compassionate patient care.

RTI International found care coordinators generally needed more training to meet new care coordination responsibilities. In addition, the 2015 demonstration projects were fraught with delay as organizations attempted to provide the breadth and depth of services necessary for true care coordination.

While demonstration projects can provide important information about the successes and challenges of launching new programs, there exists an established, efficient program with decades of success in coordinating care for dual-eligible participants: the Program of All-inclusive Care for the Elderly (PACE).

PACE is an important CMS-supported program provides coordinated care every day to dual eligibles in 32 states, reports the National PACE Association.

Back to the future

For more than 40 years PACE has proven itself as an exceptional way to provide substantial care coordination services to frail dual eligibles. The interdisciplinary teams at PACE facilities around the country understand the challenges of participants, and have the processes and systems in place to provide a smooth care coordination experience.

The team develops a care plan for each participant and meets regularly to discuss the care of PACE participants, ensuring each receives the care he or she needs.

At InnovAge, for example, PACE care coordination has led to exceptional outcomes for dual-eligible participants:

  • Nursing home stays (typically long-term placements) are approximately 10 percent for PACE participants while 13 percent for all dual eligibles.
  • Skilled nursing facility stays (generally short-term placements) are approximately 50 percent as long for PACE participants compared to high-cost duals.
  • Inpatient hospital stays of a day or more are about 50 percent as much for PACE participants compared to high-cost duals.

With the goal of ensuring participants live on their own in the community, PACE brings coordinated care to the older adult to help make this independence a reality for the largest number of participants possible through a continuum that promotes the use of technology, constant communication and an interdisciplinary team focused on the health needs of older adults.

Maureen Hewitt is the President and Chief Executive Officer of InnovAge, a Denver-based provider of comprehensive healthcare services for older adults in California, Colorado and New Mexico. Hewitt has held this role since 2006 and has led for-profit and nonprofit health care organizations for 20 years. Hewitt’s experience includes leading skilled nursing/sub-acute care facilities and acute care and rehabilitation hospitals, as well as serving in volunteer board positions. Learn more at and

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