Thursday, July 8, 2010

Long Term Care Options: A Novel Outcomes Study

What are the options when older persons can no longer live independently at home and need long term care? Many would say nursing home care. However, over the past decades, several alternative options to nursing home care have emerged.


One alternative to nursing home care is PACE -The Program for All-Inclusive Care of the Elderly. Based on the On Lok Model developed in San Francisco, PACE provides a comprehensive set of medical and social services that are managed by interdisciplinary teams based in adult day health centers. These services make it possible for most PACE patients to stay at home. PACE is only available in regions that have PACE centers.


Another option, available in almost states are Medicaid waiver programs in which elders are provided a case manager who organize the provision of inhome personal and supportive services. These services are aimed at keeping the elder at home. Resources that would otherwise go towards nursing home care support these services.


Given the enormous resources spent on long term care, and its importance to well being in the frail elderly, you would think there would be a multitude of studies to determine which types of long term care result in the best outcomes. Amazingly, there are very few studies, and we know virtually nothing about the impact of different long term care choices.


This makes the recent study by Wieland, published in July issue of the Journal of Gerontology, very timely. Wieland compared survival over 5-years in South Carolina frail elders who enrolled in each of the 3 options: Nursing home, PACE, or the waiver program. In South Carolina, patients enrolling in any of these programs were required to undergo a common evaluation process to assure they met criteria for nursing home placement. This made it possible to do this study, as it assured all elders could have been enrolled in any of the 3 options, and it made a common baseline data collection on all elders possible.


One issue with this type of comparison is that it is possible sicker higher risk elders will selectively enter one of the programs. If this were the case, elders in that program could appear to do worse simply because they started out sicker. An innovative aspect of this study was the approach to adjusting for this possibility. Wieland used a prognostic index developed by Palliative Care physician Elise Carey to control for baseline risk.


The main intiguing finding of this study: Elders enrolled in PACE had better survival. This advantage was most pronounced in medium and high risk patients. In elders with medium risk Carey scores, median survival was 2.8 years in those enrolled in nursing homes, 3.4 years in the waiver program, and 4.7 years in PACE. In elders with the highest risk Carey scores, survival was 1.4 years in nursing homes, 2.0 years in the waiver program, and 3.0 years in PACE.


So, at a minimum, this study suggests that providing supportive social and medical services makes it possible for elders who would otherwise need nursing homes to stay at home. Further, there is an intriguing possibility that innovative programs like PACE might improve survival. Unique aspects of PACE include the complete integration of medical and social care, and active management by a highly multidisciplinary team. The novel use of adult day health as the centerpiece of these programs, and the integration of the multidisciplinary teams into the day health centers means that the typical PACE enrollee is followed very intensively.


Of course, no single study of this sort can be definitive. It is possible that other unmeasured medical and social characteristics of elders in these programs explain survival differences rather than differences in the care provided by the programs. It will take additional studies and evidence from multiple sources before we can clearly know if different long term care approaches have an impact on health outcomes. The Wieland study is a crucial start in assembling this evidence base.

by: [ken covinsky]

7 comments:

Dan Matlock said...

Just used this blog in clinic today. A patient of mine is ideal for total long term care (our PACE provider). She is dual eligible, on a nursing home trajectory, really wants to stay home. The family is very frightened to change physicians.

I opened up this blog and we read it together. They are going to look into it again.

Thanks for this post.

Helen Chen said...

Thanks for the post, Ken. Often, PACE participants have higher Medicare risk scores than comparable populations (SNPs, instituationalized Medicare beneficiaries). It is good to see that the literature supports the observation that many PACE participants really do better in the program. In many ways, PACE is an exemplar of a patient centered medical home--it is rarely if ever said that "you are in the wrong room" for this problem"--and the positive outcomes that can be achieved with a true PCMH.

Ken Brummel-Smith said...

Ken mentions two important aspects of PACE - integration of the medical and social aspects of care and the interdisciplinary team. But another aspect is just as important - prospective, globally capitated funding. As a former PACE medical director, it was wonderful to realize that we never had to think whether something was "covered" by Medicare or Medicaid. We could just think about what the participant (they are not called "patients" in PACE) needed.

Jane Marian said...

There are many new technologies that are allowing seniors to keep their independence for longer amounts of time. I read about something like a "check-in" device. Basically, seniors (or anyone that needs it) that are living along have to push a button every day, or twice a day, and if they don't push the button by a specific time, someone they know that lives nearby or a son or daughter gets notified. I only see more technologies improving lives. www.silvercensus.com

LeighSW said...

Very intriguing! I hope there will be more studies done on this issue.

Ramya said...

Just linked this article on my facebook account. it’s a very interesting article for all.


Day Care Centres

nursing home said...

Not only in Michigan, long term care benefits are also given to seniors living in San Francisco and Alaska.