Providing services to the elderly is a growing need for the medical practice administrator. With the growth in this demographic, healthcare models are shifting to provide more services for seniors.
One of the most unique models for healthcare delivery to seniors is the Program of All-Inclusive Care for the Elderly (PACE), a Medicare and Medicaid program that helps elderly people meet their healthcare needs in the community instead of receiving care in nursing homes or other care facilities. PACE programs provide home and community-based services (HBCS) through the member’s home, community and a PACE center.
The Body of Knowledge for Medical Practice Management (BOK) is fundamental to successful medical practice administrators in traditional healthcare settings and also beneficial to successful PACE program administrators.
Since PACE programs deal with the highest risk population in healthcare, the knowledge to create and maintain a safe environment is crucial.
Introduction of a PACE program
A PACE program is a medical clinic, an adult day care center, a home care provider and a medical transportation service all rolled up into a single healthcare delivery model. It is a home- and community-based service business.
The PACE model is centered on the belief that it is better for the well-being of seniors with chronic care needs and their families to be served in the community whenever possible. PACE serves individuals 55 and older who are certified by their state to need nursing home care, can live safely in the community at the time of enrollment and live in a PACE service area. Even though PACE enrollees must be nursing home eligible, only 7% of participants reside in a nursing home.
The PACE model can be traced to the early 1970s, when the Chinatown-North Beach community of San Francisco saw the pressing needs for long-term care services by families who immigrated from Italy, China and the Philippines. Community leaders formed a nonprofit corporation called On Lok Senior Health Services. “On Lok” is Cantonese for “peaceful, happy abode.” The model expanded in the late 1970s, and in 1990, the first PACE program received Medicare and Medicaid waivers to operate.
The 1997 Balanced Budget Act establishes the PACE model as a permanently recognized provider type under both Medicare and Medicaid. In 2016, there were 116 PACE programs in 32 states serving 35,000 enrollees.
PACE services include, but are not limited to, the following: adult day primary care (including doctor and recreational therapy nursing services), dentistry, emergency services, home care, hospital care, laboratory/x-ray services, meals, medical specialty services, nursing home care, nutritional counseling, occupational therapy, physical therapy and prescription drugs. PACE also includes all other services determined necessary by the team of healthcare professionals to improve and maintain the overall health of the PACE member.
An interdisciplinary team (IDT) of professionals provides the member with a coordinated care plan. The IDT professionals (primary care physicians, physician extenders, nurses, social workers, physical therapists, occupational therapists, speech therapists, activities coordinators and dieticians) work together with the member and the member’s family to develop the most effective plan of care.
Supporting and fulfilling the work of the IDT is the administrative role of the center manager (CM) and executive director (ED), who both serve as program administrators.
PACE program administration is a very complex, highly regulated environment. Although no specific credential is needed to serve in an administrative role for a PACE program, experience in care of the elderly and a solid management background are recommended.
Operations management
As an administrator, operations management requires an understanding of business operations and effective management of the program.
You must apply your knowledge of healthcare rules and regulations daily. A PACE program is a highly regulated business, so you must ensure compliance on a local, state and federal level.
The program deals with a high-risk patient population of the frail and elderly. As administrator, you are expected to provide healthcare, help members maintain their independence and ensure their safety within the community. Demonstrating your ability to provide a high-quality and safe environment is the cornerstone in managing the program.
Financial management
Financial management requires skills in accounting, budgeting, revenue cycle management and financial analysis.
The administration of a PACE program requires the management of a managed care health plan. The state and federal governments pay on a capitated per member, per month basis. As a managed healthcare program, the PACE program must be successful in controlling expenses and providing quality services to members.
With this type of payment model, you must demonstrate knowledge of the payment regulations, as well as the ability to manage cash flows, accounts payable and payroll systems.
Risk and compliance management
Since PACE programs are dealing with the highest risk population in healthcare, the knowledge to create, implement and maintain a safe environment is crucial.
Seniors are at risk for falls — the elderly account for 75% of all deaths from falls.1 As an administrator, your program will need to be able to minimize the impact of adverse events using risk prevention strategies and the multidisciplinary approach of your organization. You must also know how to develop, implement and maintain a compliance program according to the regulations.
Unlike traditional medical practices, PACE programs are solely funded by state and federal programs and not for-profit insurance or third-party companies. This means that as an administrator, your ability to handle compliance is necessary to remain a participating provider in these programs.
Organizational governance
Because PACE programs are very defined by the state and federal government, your role as an administrator involves the ability to understand the legal structure, as well as organizational policies and procedures.
As PACE programs grow and mature throughout the country, the need for highly trained medical administrators is equally growing.
The administrator must be able to define the types of committees within the organization and oversee the effectiveness in the overall mission. Some key committees for a PACE program include infection, wound, fall, safety and quality assurance/process improvement.
Clearly, as the leader of the organization, you must be able to integrate the corporate mission, vision and values into the organizational culture.
Patient-centered care
The entire basis of the PACE program is built around a member/patient-centered approach. The mission is to partner with the member, family and community to enable seniors to remain at home while preserving dignity and autonomy.8
An administrator must facilitate a care coordination process that leads to the best management of the elderly and ensures the quality of the care they receive. The program must establish communications, standards of care and quality measures. PACE programs have very defined processes for service delivery, grievances and appeals. The administrator needs to ensure that this process is compliant with regulations and that it meets members’ needs.
Summary
The current models to deal with the growing needs of the elderly populations have been developing across the country for over 40 years. One such program, the PACE program, has been providing for all-inclusive care of the elderly and maintaining dignity and patient independence with the goal of keeping seniors in their homes and communities.
As PACE programs grow and mature throughout the country, the need for highly trained medical administrators is equally growing. The demands of operating this model require the skills present in the BOK. The six domains of the BOK are evident in the duties and tasks for management positions such as CM and ED, as they serve as the administrators for the program.
It is important that the success of the PACE programs attract medical administrators possessing the skills outlined in the BOK.
Note:
1. Mission statement. SeniorLIFE. January 2016.
Providing services to the elderly is a growing need for the medical practice administrator. With the growth in this demographic, healthcare models are shifting to provide more services for seniors.
One of the most unique models for healthcare delivery to seniors is the Program of All-Inclusive Care for the Elderly (PACE), a Medicare and Medicaid program that helps elderly people meet their healthcare needs in the community instead of receiving care in nursing homes or other care facilities. PACE programs provide home and community-based services (HBCS) through the member’s home, community and a PACE center.
The Body of Knowledge for Medical Practice Management (BOK) is fundamental to successful medical practice administrators in traditional healthcare settings and also beneficial to successful PACE program administrators.
Since PACE programs deal with the highest risk population in healthcare, the knowledge to create and maintain a safe environment is crucial.
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