It’s been about three and a half years since Linda Cranmer’s left leg was amputated a few inches below the knee.
“It was blood clots,” she said. “I was supposed to have a tumor taken out of my head, but I ended up losing my leg.”
At the time, Cranmer, then 62, was living in Scranton, a small town about 20 miles south of Topeka.
“I got to a point where things were so bad I just stayed in my room. I didn’t want to live anymore,” she said.
Then, about 18 months later, Cranmer was able to get into the PACE program, and things began to look up for her.
“PACE has been a miracle for me,” she said. “It’s made me want to live again. The people here don’t let you give up.”
PACE stands for Programs for All-Inclusive Care for the Elderly, a Medicare- and Medicaid-funded managed care program for people who are 55 or older, low-income and close to being admitted to a nursing home.
The program has been a relatively small player in Kansas’ efforts to help frail seniors such as Cranmer avoid expensive nursing home care but is poised to take on a much larger role.
The Kansas Department for Aging and Disability Services recently announced plans to broaden the state’s Programs of All-Inclusive Care for the Elderly, a managed care option better known as PACE.
Since the mid-2000s, PACE has been available in eight Kansas counties. Starting next year, it will begin a planned multiyear expansion into 51 additional counties.
“This is a good thing,” said Janis DeBoer, executive director of the Kansas Area Agencies on Aging Association. “It’ll give individuals who are over (age) 55 and who are on Medicaid and Medicare a fourth choice. Depending on where they live, they can go with one of the three managed care companies in KanCare or they can go with PACE. It’ll depend on whatever plan they’re comfortable with and whichever one they think will best meet their needs.”
KanCare refers to the Gov. Sam Brownback-led initiative, now in its second year, to let three for-profit corporations — Amerigroup, UnitedHealthcare and Sunflower State Health Plan, a subsidiary of Centene — manage the state’s Medicaid programs.
The two PACE providers in Kansas — Via Christi Health of Wichita and Midland Care of Topeka — are nonprofit and rely on their own networks of physicians, nurses, pharmacists, dentists, physical therapists, social workers, case managers, in-home caregivers and drivers.
“The KanCare plans provide care coordination, but they’re not the direct service provider. They contract out for services,” said KDADS Secretary Shawn Sullivan. “PACE does care coordination as well, but it employs its own service providers. Its service network is much more tightly controlled.”
Also, he said, the PACE model relies on patients being transported to a network of adult day centers designed to keep close tabs on their health care needs. KanCare companies depend more on less-frequent in-home visits.
While PACE patients are likely to visit with a nurse one to four times a week, KanCare patients see nurses once or twice a month. PACE patients’ health care needs tend to be more complex than their KanCare counterparts.
The KanCare companies and the PACE providers are paid a capitated rate for each patient in their care. The rates vary, depending on an enrollee’s overall health care needs.
The managed care companies, according to Kansas Department of Health and Environment reports, are paid about $3,200 a month for each beneficiary who’s on both Medicaid and Medicare; PACE providers receive between $2,400 and $3,100.
To be in PACE, individuals must be 55 or older, eligible for Medicaid and Medicare, live in one of the designated counties and need nursing home-level care but want to remain at home.
Generally, disabled adults are eligible for Medicare if they’ve been on Medicaid for two years.
Medicare is more “catastrophic care” type coverage – hospitalization, skilled nursing, in addition to basic medical and “Part D” prescription coverage.
Medicaid, as a “poverty” program, covers the Medicare premium costs for beneficiaries and provides more health care type benefits – prescription glasses, prescriptions, diagnostic/preventative care - depending on what a state elects to offer under the program.
“Anyone who’s enrolled in KanCare and who’s Medicare- and nursing-home eligible can switch to PACE during the open enrollment period,” Sullivan said. “Or, throughout the year, they can disenroll (from KanCare) and go to PACE.”
The PACE programs, he said, “don’t get to cherry pick;” they have to take any patient who is eligible and completes the application process.
Today, only 337 of the 11,900 Kansans known to be eligible for PACE are enrolled in the program.
“There are a couple reasons for that,” said Robert Greenwood, vice president of public affairs with the National PACE Association. “The first is you have to live in one of the counties in Kansas that are designated PACE service areas. That’s the biggest factor.
“The second is that a PACE program is centered around an interdisciplinary team that’s housed at a day health center,” he said. “A team can only enroll about 150 to 180 people; after that, (PACE) has to develop another team and another site. That doesn’t happen overnight.”
Sullivan said the program’s expansion could lead to an additional 1,100 Kansans signing up for the program over the next two to three years.
“Studies show that PACE participants have improved health status, quality of life, lower mortality rates, more and better choices over how to spend their time and greater confidence in their ability to deal with life’s problems,” he said.
Historically, legislators have been reluctant to put money into the program.
“Early on, there may have been some misunderstandings on the full ramifications of PACE,” said Rep. David Crum, an Augusta Republican and chair of the Legislature’s Bob Bethell Joint Committee on Home and Community Based Services and KanCare Oversight. “But I think (KDADS) Secretary Sullivan brought some new perspective on how PACE fits in with KanCare and with our wanting to provide services in the most efficient manner when it comes to keeping people in their homes rather than a nursing home.”
Starting next year, Via Christi Health will begin expanding its Sedgwick County-based PACE program, called Via Christi HOPE, into Johnson, Miami and Franklin counties.
The program, according to a Via Christi HOPE spokesperson, has yet to set a timeline for expanding into Butler, Cowley, Harper, Kingman and Sumner counties, all in south central Kansas, or into 15 southeast Kansas counties: Allen, Anderson, Bourbon, Chautauqua, Cherokee, Coffey, Crawford, Elk, Greenwood, Labette, Linn, Montgomery, Neosho, Wilson and Woodson counties.
Midland Care is expected to expand its seven-county region (Douglas, Jackson, Jefferson, Osage, Pottawatomie, Wabaunsee and Shawnee) to include Lyon, Marshall and Nemaha counties sometime in 2015. It also formed a partnership with Kansas City Hospice and Palliative Care for making PACE available in Brown, Doniphan, Atchison, Leavenworth and Wyandotte counties.
“Our first expansion site to the east will probably be in Wyandotte County by July of 2015, and in Leavenworth and Atchison counties sometime in the next 24 months, depending on how the program grows,” said Midland Care Chief Executive Karen Weichert. She declined to be more specific, noting the proposed projects are still in the early stages of a federal application process that “takes anywhere from six to 12 months.”
Bluestem Communities, a Hesston-based organization that runs the Schowalter Villa and Kidron Bethel Village retirement communities in Hesston and North Newton, respectively, has been awarded the PACE contract for 20 counties in north central Kansas: Chase, Clay, Cloud, Dickinson, Ellsworth, Geary, Harvey, Jewell, Lincoln, Marion, McPherson, Mitchell, Morris, Ottawa, Reno, Republic, Rice, Riley, Saline and Washington.
“We’re planning on sort of a three-phase approach,” said James Krehbiel, chief executive at Bluestem Communities. “The first phase will be an eight-county region that will include Harvey County, Hutchison, Salina and McPherson. The second will be in Riley and Geary counties and some of the surrounding area. In the third phase will get into the more rural areas.”
The rollout, he said, may take three to four years to complete.
“This is a brand-new program for us,” Krehbiel said. “But we have a long history in the care-providing business, we’ve been working very closely with Via Christi HOPE, we’ve been visiting with other PACE programs around the country and we’ve brought in a consultant who’s worked with a lot of different PACE programs. We see this as a natural extension of what we’re already doing.”
Krehbiel said he hoped Bluestem Communities eventually will take on 240 PACE patients.
Mitzi McFatrich, executive director at Kansas Advocates for Better Care, a group that represents nursing home residents and their families, said she welcomed news of the PACE expansion.
“We’ve always been a fan of PACE programs,” she said. “They do a lot of things well.”
Ami Hyten, assistant director at the Topeka Independent Living Resource Center, said PACE has advantages and disadvantages.
“It all comes down to choice,” she said. “If you want to self-direct your care or if you already have someone you want to be your caregiver, you’re probably not going to want to go with PACE because you have to use whoever’s in their network. But if you’re OK with that, then, fine, you may want to go with PACE. It’s a good program.”
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