Keeping PACE with the Rural Elderly

by Kathleen Belanger

It's summer, and we are literally enjoying the fruits of our labors: tomatoes.  There is absolutely nothing like a fresh ripe tomato, unless it's the taste of tomatoes in winter.  That's why I have been spending hours each week freezing them, making tomato sauces and spicy salsas—because I want winter to be almost as bright as summer.

I think of our rural families and friends entering the winter of their lives.  How can we brighten those days, particularly when these elders are also near the end of their resources?  PACE, the Program of All-inclusive Care, is a "comprehensive and seamless service delivery system" for those 55 years or older who meet clinical criteria for nursing home admission. It is designed to help elderly people remain independent by providing not only access to health care from a medical team, but also social services. In fact, social services are a requirement for PACE programs. The program utilizes integrated Medicare and Medicaid financing, and is the sole source of services for Medicaid and Medicare eligible enrollees.

According to Mitch Leupp, Executive Director for Northland PACE in North Dakota, which has programs in Bismarck and Dickinson, PACE is unique.  The staff's concern is with the whole person, what elders not only need for health, but what they want in order to remain in their homes.  The social worker or human service provider builds relationships with the elder, with the family, and between them and the health team.  Amy Thom, MSW, a licensed social worker with Northland PACE, describes the wishes of a 97 year-old woman who had seriously declining health but desperately wanted to be home. PACE was able to work with the family to provide as much as possible in the home for the longest time.  Even after having to spend some time in a nursing facility, she was able to return home to celebrate her 97^th birthday—with her family, PACE staff and site manager, and her physician—and she died a few days later at home in her chair.  A rural veteran was in such poor health and in such need of social support that he was a frequent utilizer of emergency room and in-patient hospitalization.  With Northland PACE's medical treatment and oversight, and particularly with the emotional support that regular visits provided, the veteran's health was restored and his hospital admissions drastically reduced, while his overall well being significantly improved. "I never imagined that life could be this good again!" he declared.

According to Cherie Denning, LSW, Northland PACE Intake and Enrollment Coordinator, one of the greatest benefits is that frequent visits and contact with the client and family allow social workers to be the eyes and ears of the medical staff. "Sometimes physicians don't have the real story," Denning explained, "and we can help clarify what's really happening, since we are in the home."   Because services are better coordinated, and because there are services provided, like housekeeping or nurse aide services, staff members learn about other challenges that may need to be brought to the whole team's attention. This contact gives physicians more and better information, reducing the need for tests.  The better information allows "doctors to be doctors" according to Leupp.  Family members don't have to serve as coordinators and deliverers of many of those services, "allowing families to be families" according to Denning.  And since rural communities have far fewer services available, the care coordination, case management and social services provided by PACE can make all the difference to an elder and his or her family.

According to SAMHSA's National Registry of Evidence-Based Programs and Practices, PACE has evidence to support its use with the elderly population.  Studies comparing PACE participants with comparable non-PACE recipients found that significantly fewer PACE participants felt depressed, hopeless or worried, and spent less time in a hospital or a nursing home the previous year.  They had significantly lower rates of hospital, nursing home and emergency room utilization, and fewer inpatient hospitalization days. In addition, more PACE participants received vision and hearing screenings, pneumonia vaccines and flu shots.

I have begun to think of my own winter.  In my rural community, there is no well-coordinated system of health and human services available to me as I age—perhaps one of the costs for living in a town where I can have a huge garden only blocks from downtown.  My children assure me that if I need help they will be there to care for me, as I cared for my own parents.  But do I really want to impose? Will I have to try to find my own social services, my own housekeeping and nursing staff, someone to call when I have a medical question, aides to assist with personal care and transportation?  My children won't be able to do it from afar.  Will I have to move to their cities, depend on them and their families?  Maybe I need to start thinking about helping start a PACE program here, at least while I can still put up my own tomatoes.

Kathleen Belanger, Ph.D., is Professor of Social Work at Stephen F. Austin State University in Nacogdoches, Texas, and is a member of the RUPRI Human Services Panel, and recipient of CWLA's Champion for Children award in 2005 for her work in rural child welfare. Belanger has published and presented on rural human services issues in a variety of publications and forums. In addition, she has worked for more than 20 years with rural communities, where she has helped found several non-profit organizations and advocated for rural resources.

Opinions expressed in this column are those of the author and do not necessarily reflect the views of the Rural Health Information Hub.

Back to: Summer 2014 Issue