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Home-based care providers and Program of All-Inclusive Care for the Elderly (PACE) organizations are in a unique position to strengthen the work one another is doing to care for seniors.
No one understands this better than Alivia Care, a home-based care provider that also has PACE programs under its umbrella. In 2021, Alivia Care opened up Jacksonville, Florida-based The PACE Place.
“We thought No. 1, it related to the type of care that we gave, in terms of chronic elderness, geriatric frailty, many of the things that we see in our hospice patients, so we felt that we had some core competencies there,” Alivia Care CEO Susan Ponder-Stansel told Home Health Care News. “One of the things that we also wanted to do is just practice being responsible for the total cost of care, over a longer period of time.”
Jacksonville, Florida-based Alivia Care provides home health care, hospice care, personal care, palliative care, advanced care planning and PACE services across Northern Florida and Southern Georgia. Currently, The PACE Place serves roughly 150 seniors.
Ponder-Stansel has seen opportunities to bring in its home health resources to benefit the seniors who are receiving care through the company’s PACE program.
“We found that it was actually better to work with our home health agency, especially for things like wound care,” she said. “Home health [clinicians] have certain skill sets that most are very good at, things like wound care or cardiac rehab or diabetic education, some of those things that we would see in our PACE population. Some PACE providers just do it all themselves, so it depends on what works for them, but we felt this was a better way.”
In addition to this, Alivia Care utilizes its personal care staff to offer transportation escorts for medical appointments to seniors receiving PACE services through The PACE Place. These caregivers are also providing support in the home, delivering housekeeping services and help with chores.
On the other end, the company has been able to bring PACE services into the home.
“Not every PACE participant will come into your day center every day,” Ponder-Stansel said. “There are times when people just don’t feel well. We’ve been able to do occupational therapy, physical therapy, and bring that to the home for them. Because PACE is the payer for this, you don’t have to necessarily go through all the hoops of the OASIS. You can just contract with your home health to provide it.”
Referral-based partnerships
One Senior Care is a PACE organization that has formed referral-based partnerships with home-based care providers.
“Oftentimes it’s those home health companies that really know and see the conditions that the patients are living in, and really have a good understanding of the complexity of these patients,” Craig Worland, chief operating officer at One Senior Care, told HHCN. “They’re the ones who realize that the patient may need more, and they actually can be a referral source for us.”
Erie, Pennsylvania-based One Senior Care is the top PACE provider for rural and Appalachian communities.
Similar to Alivia Care’s The Place Place, One Senior Care also brings its home-based care partners into the home of PACE participants that need additional support.
“There are definitely times where there’s a skilled need that we don’t have at a center within our staff, or there is something that a patient needs just due to how complex they are that we are not equipped to provide,” Worland said. “We work with the home-based care company to provide that.”
The biggest value-add of these partnerships is being able to offer an additional level of care through working with home-based primary care and home health providers, according to Worland.
“That to me is really the sweet spot for these partnerships, it’s allowing us to meet our goal, which is keeping the participant at home, that could be anything from wound care to infusion [services],” he said.
Despite PACE and home-based care providers being natural allies, Worland believes that the latter are sometimes reluctant to collaborate with the former.
“Sometimes home-based care companies view PACE as a competitor, and they almost have an aversion to working together, or an aversion to using PACE as a resource for their really sick patients,” he said. “I think what I’d love to see is just more of that collaboration.”
For Alivia Care, the internal partnership between its home-based care arm and its PACE program has meant leaning into each segment’s strengths, as opposed to taking everything on.
This doesn’t mean the collaboration is completely free from challenges.
“Coordination and communication is something that is sometimes challenging, and you have to build in mechanisms for hearing from those who are providing the care in the home, and then having them coordinate with your interdisciplinary care team to manage that care and make sure you’re responding to anything that’s going on, and planning adequately,” Ponder-Stansel said. “There’s a higher degree of communication than you would normally see with a Medicare patient.”
Worland also stressed the importance of strong communication within these partnerships.
Ultimately, he wants home-based care providers to understand the mutual benefits that come from teaming up.
“The onus is on the PACE plan to explain that and spell that out, but as patients continue to get sicker, get more complex and their care needs become more challenging, I really want these home care companies to be thinking about PACE as a partner,” Worland said.
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