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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When asked to summarize the company’s 2024 thus far, InnovAge Holding Corp. (Nasdaq: INNV) CEO Patrick Blair called it “a year of continuous improvement.” 

One of the reasons for this is that — after putting its regulatory challenges in the rearview — is the company continuous fine-tuning of compliance. 

It has also assembled a management team that Blair believes will help InnovAge grow and scale responsibly. Its ability to manage medical costs effectively is already there.

As InnovAge keeps moving forward, Blair has begun to think about the broader future of Program of All-Inclusive Care for the Elderly (PACE), too. 

“I tell people, PACE is the best kept secret in health care, and we’ve got to do a much better job of creating awareness of the value that it delivers. We have to ​​ensure the program flourishes, over the long term. That’s a hard business objective of the company,” Blair told Home Health Care News.

During a conversation with HHCN, Blair also revealed where InnovAge currently stands with the Centers for Medicare & Medicaid Services (CMS) and other regulators, why home-based care is integral to PACE and how a recent acquisition allowed the company to rapidly expand. 

In 2022, the company went through some very public regulatory challenges with Colorado’s Department of Health Care Policy and Financing and CMS. Looking back, walk me through how the company was able to turn things around, and where does InnovAge stand now?

It starts with the relationship. The first thing we really needed to do was start engaging deeply with CMS and our state partners. In that case, it was both Colorado and California, and using the audit findings as a roadmap for opportunities for improvement. We had regular working sessions with them, where they provided us input and direction based on their audit findings. For each of the deficiencies that were identified, we went through a very rigorous root cause analysis and identified whether the root cause of the issues were related to people, process, technology, or documentation, and then we developed action plans for each of those areas of opportunity. We assigned an accountable leader in the organization to lead the remediation effort. We would communicate our progress to our regulatory partners on a regular basis. It was generally monthly, against a set of jointly developed audit performance measures that we were holding ourselves accountable to, and they were holding us accountable to. We just kept them informed of our progress every step of the way, and followed up quickly on all their requests to ensure they were completely satisfied with our improvements we were making, and the quality care we are providing.

Ultimately, I think it gave all the regulators a lot of confidence that we had resolved the issues. The standard for the audits is that the regulators don’t believe that they’ll occur again in the future. It was a challenging period for the company, but I believe we possess all of the operational experience, the capabilities, and the commitment to quality care, to be a market leader in all ways, including compliance.

In general, what are some of the biggest operational or financial challenges in the PACE space, and how is InnovAge navigating these issues?

The first would be ensuring we receive rational reimbursement rates each year from our states that are reflective of the population that we serve, and that it accounts for all the drivers of annual health care inflation. Receiving those rates, that’s where it starts with a PACE program being able to invest in the tools, the technology and the people to help keep seniors safely in their home. Our overarching approach is to be much more proactive and data-driven in our rate discussions with states. 

We believe that the PACE model drives meaningful savings for our government partners when they compare it to other alternatives. It’s really incumbent on us, and we’ve spent a lot of time on building the skills and the capabilities to empirically demonstrate the value we’re delivering and ensuring and making the case that we’re being paid a financially suitable rate for the services that we offer. One of the keys, in some ways, has been adding a very experienced actuary to our team. Someone who has extensive experience in Medicaid managed long-term care program rate setting and rate advocacy strategies with states. That was an important investment we made to help us navigate that challenge.

On the operational side, I mentioned administrative process barriers that delay enrollment. These can take the shape of delays in processing Medicaid applications, or constraints on the state’s part, conducting the necessary level of care assessments to determine need and eligibility. In PACE, the enrollment process is really a joint effort between the PACE program and the state partner. In some cases, the state uses subcontractors to perform assessments, or to validate our assessments. Ultimately, they process the applications. When there’s delays there it can result in people seeking other solutions, or having a longer time to service, from when they first express their interest.

We’re fortunate that our states are very open to working with us to implement process improvements, and to ensure that everyone who qualifies and needs PACE has a path to coverage. We hired a new head of government affairs that has a lot of deep operating experience, legislatively, in the regulatory environment — as well as in the community stakeholder environment — that’s really helping us engage in productive discussions on these topics. We’ve been able to create a repeatable and a scalable platform. 

We’ve recently seen the introduction of the PACE Anytime Act. Can you talk about the significance of this bill? How likely is this to gain traction?

It relates back to the prior question, in terms of what are some of the operational barriers that PACE programs encounter. It’s really exciting to see the increasing support for administrative and operational changes that would make it easier for us to qualify seniors to join PACE. This proposed bill, at its core, is about allowing qualified seniors to enroll anytime during the month, rather than just limiting enrollment to the first of the month. It could be tremendously impactful legislation, if passed. It would be incredibly helpful to us in closing any potential gaps in care, as seniors transition to PACE. Many of our PACE participants are very frail with acute needs for coordinated medical care, and home- and community-based services. Any regulatory change that can help accelerate the speed to clinical service is a wonderful thing.

From our perspective, the bill is very consistent with the work that MACPAC is doing on timely level of care, redeterminations. I think they had a report out in April, but both of these are sort of evidence of the increasing public policy focus on getting these seniors the services they need without unnecessary delay. As the PACE program grows, one of the most challenging processes is the level of care determination performed by the state or their designee. We’re starting to see more momentum across the federal regulators and states, as it relates to their commitment and dedication to reducing administrative barriers for entry into PACE.

Staying on legislation, what else would you like to see lawmakers include in future legislation that aims to expand PACE?

I think that legislation or regulatory changes that address the key challenges that are hindering PACE growth, in areas such as administrative requirements, approval timelines for new market expansions, enrollment processing barriers and turnaround times, eligibility limits for some populations that could benefit from PACE and marketing restrictions that can disadvantage PACE, relative to other options in the community, I think we need to keep pushing on all of these at the state and federal level.

Anything that reduces barriers to access can just be very important for our seniors of the community. 

How is InnovAge collaborating with home-based care providers? In general, what opportunities are you seeing here?

As a Bayada alumni, I’ve seen firsthand the impact that great home-based care can have on the quality of care, that it can have on the families who are trying to support their loved ones, and on the total cost of care. It’s an integral part of the PACE program and its success. The model is designed to enable seniors to age in their homes and on their own terms, and critical to that effort is us meeting them where they are. While our participants actively attend our centers regularly, many still require assistance in their homes with both skilled and unskilled care. They spend more time there than they do in our community-based centers. I think maybe 40% of our participants are taking advantage of home-based care services. We complete about 400,000 in home visits per year. The support is tightly integrated with and overseen daily by our interdisciplinary team. They’re in a position to help provide us with the eyes and ears of what’s happening in someone’s home. There has been changes of condition in a period of time since they’ve been in the center. We employ most of our home care professionals, and they’re in real-time coordination with the primary care physician to ensure we’re keeping the people safe in their community, so skilled and unskilled care are a big part of our core delivery model. 

We also are starting to use more physician care in the home. That’s another area where we might have individuals that are very frail in need of more specialized care, and sometimes more urgent care. We use a number of partners to help provide a much more expansive set of services in the home, when necessary, and when we do a good job at this, fewer people get admitted to the hospital. That’s better for the participants, better for their families, and better for the PACE program. 

Going forward, I think there’s a lot of opportunity, in some ways, to expand the definition. We’re starting to build mental health capabilities that can be deployed to the home. We’re starting to think of creative strategies around what are historically known as personal emergency response partners.

Last year, InnovAge acquired two PACE programs in California from ConcertoCare. Can you give readers an update on this? What has acquiring these programs allowed InnovAge to accomplish?

In some ways, we consider this transaction more of a hybrid between an acquisition and a de novo market entry because it included a recently opened center in the Crenshaw neighborhood of Los Angeles, with very minimal census. It also included another center in the final stages of the application for licensure in Bakersfield. In some ways, this is a bit of a hybrid, in that one was operational and very new, and one was not yet operational.

We were looking at several alternatives to continue responsible growth in the California market. These centers allowed us to move faster and more cost-effectively to expand in the market, compared to building new centers from scratch, while also enabling us to implement our operating model from Day One. 

California is a very attractive market, given the state’s commitment to ensuring seniors have a comprehensive set of home- and community-based care options. Obviously, there’s a large population of PACE eligibles, and it’s not only large, but it’s growing. The ConcertoCare acquisition allowed us to have a much more rapid expansion than we would have otherwise been able to achieve without it.  

How much does M&A factor into your future growth plans?

We view ourselves as having a multi-prong growth strategy that consists of organic growth, or growing in our existing centers, what we call de novos, or new market expansions, new geographic expansion, and M&A.

I would say that we’ve prioritized filling our existing centers. Priority No. 1 is just making sure that we have capacity in our centers. We will continue to be opportunistic and will always engage in discussions with potential opportunities from an acquisition perspective, but job one is responsible growth within our existing centers.

As CEO, what are your goals for the rest of the year, and what are you focused on for 2025?

It starts with making sure we have the best people in every job, and that we have a highly motivated, engaged workforce of caring people with an owner’s mindset.

We want each of our centers to serve more seniors every month, especially our new centers. We want to continue to capture the value from our Epic investment to help us become more efficient, more productive and to improve quality of care. We want to continue on the great path we’ve been on related to quality and compliance. I want to see continuous improvement there.

More broadly, we want to demonstrate and strengthen PACE’s value proposition relative to other types of value-based care models. We’ve created a platform that not only allows us to deliver high-quality care in all of our geographies, but we’ve also built capabilities to help us better manage capitated risk and improve economic performance.

Government programs are massive, and they’re growing, and the U.S. is spending more than a trillion dollars on Medicare and Medicaid. We know that the cost of care is unsustainable, and we know that patients are often dissatisfied with the care they receive, and we just believe there’s a tremendous market opportunity there for PACE, and other organizations, like ours, to deliver a comprehensive win-win value proposition. That’s a big goal of this next year, is to continue to position PACE as a solution.

I tell people, PACE is the best kept secret in health care, and we’ve got to do a much better job of creating awareness of the value that it delivers. We have to ​​ensure the program flourishes, over the long term. That’s a hard business objective of the company.

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On Thursday, U.S. Senators Bob Casey (D-Penn.) and Mike Braun (R-Ind.) — chairman and ranking member of the U.S. senate special committee on aging — introduced the bipartisan PACE Anytime Act.

The National PACE Association has thrown its support behind the legislation.

“It is difficult to get legislation passed during an election year, but we are grateful for the interest of members of Congress working toward improving access to PACE,” Shawn Bloom, president and CEO of National PACE Association, told Home Health Care News in an email. “Each bill introduction also raises awareness of the value of PACE.”

If enacted, the legislation would allow PACE-eligible individuals to enroll in the program at any time during a month. Currently, seniors are only able to enroll in a PACE program on the first of the month.

This enrollment restraint delays care by creating a roadblock for seniors that have changing needs.

“PACE programs allow seniors and people with disabilities to receive all of their essential care while remaining in their communities,” Casey said in a press statement. “While the PACE program provides high-quality, comprehensive care, limited opportunities to enroll have made the program unnecessarily difficult to access. My new bill will make it much easier to enroll in the PACE program and give seniors and people with disabilities the flexibility to receive the care they need.”

In addition to removing this enrollment rule, the legislation would also create the ability to prorate capitation payments to account for varying PACE enrollment dates.

This isn’t the first time Casey has made senior care a priority.

Most recently, Casey introduced a bill aimed at improving the long-term care Ombudsman program.

On the home-based care side, he was part of a group of policymakers who introduced a bill aimed at strengthening the long-term care workforce in April.

Ultimately, Bloom reiterated the need for increased access to PACE programs.

“PACE could be an ideal model of care for many thousands of people who currently cannot access it,” he said. “Increased access to PACE would help solve an intrinsic challenge that the country now faces, that of caring for our nation’s elderly population.”

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“Bringing Jeff on board is a huge lift for New Day as we continue to ‘Burn the Ships’

and change the way home health care is delivered,” New Day CEO G. Scott

Herman said in a press statement. “Jeff has an extensive history with our team and is an outstanding leader driven by operational excellence. Jeff is one of the industry’s most thoughtful professionals and his ability to problem solve is unmatched. He is perfect for this endeavor and I am thrilled the organization has evolved to a level we are able to capture his expertise.”

Founded in 2020, New Day has close to 30 locations across Texas, Missouri, Kansas and Illinois. The company offers a variety of home-based care services. New Day serves nearly 120,000 patients annually.

Most recently, Bonham served as senior vice president of home health at Empath Health.

“I am excited to be leading this innovative initiative with this market leading company,”

Bonham said in the statement. “Innovation is a staple of this leadership team, with whom I have a long history and have experienced many market leading successes.”

Welcome Health names new chief growth officer

Welcome Health — SCAN Group’s in-home senior primary care arm — has appointed Jay Bakshi as its new chief growth officer.

“We are excited to have Jay in this role as he brings extensive experience in partnering with payers in value-based arrangements to bring innovative solutions to the members they serve,” Welcome Health CEO Emily Cook said in a press statement. “Welcome Health has established a growing presence in Southern California, and we look forward to bringing our unique, high-touch primary care model to additional health plans and seniors across the nation.”

SCAN Group, a nonprofit organization focused on helping older adults age in place, launched Welcome Health in 2021.

As chief growth officer, Bakshi will be in charge of growth, market expansion, payer business development and contracting, account management and patient acquisition and retention.

“Welcome Health’s physicians and interdisciplinary teams holistically and expertly serve seniors where and when they need it, creating new access and improved quality of care,” Bakshi said in a statement. “I proudly make the Welcome Health mission my own — to eliminate the health obstacles preventing seniors from achieving what matters most.”

Previously, Bakshi served as finance lead for the state-sponsored businesses at Healthfirst, one of New York’s largest health insurance plans.

BoldAge PACE promotes Dr. Glenn Meyers to CMO

BoldAge PACE, a provider of Program of All-Inclusive Care for the Elderly, has promoted Dr. Glenn Meyers to the position of chief medical officer.

“Dr. Meyers has been an invaluable member of BoldAge’s team,” BoldAge Pace CEO Mary Austin said in a press statement. “His experience and compassion have allowed us to help older adults live a meaningful independent life at home, with grace and dignity.”

Prior to the promotion, Meyers served as senior medical director at BoldAge PACE. One of his chief accomplishments has been standardizing the organization’s clinical operation.

As CMO, he will be in charge of implementing his model across BoldAge PACE’s sites in California, Florida, Illinois, Indiana, Kentucky, Ohio and South Carolina.

“I am honored to join a leadership team that puts people first,” Meyers said in the statement. “BoldAge PACE is a values-driven organization that exceeds expectations by providing more to our participants than I ever saw during my time in Medicare Advantage. Our participants rely on us to meet their needs, and we proudly fulfill that promise every day.”

Home Care Alliance of Massachusetts Board of Directors appoints new chair

Renee McInnes has been appointed to chair of the Home Care Alliance of Massachusetts Board of Directors. McInnes currently serves as CEO of NVNA and Hospice.

The Home Care Alliance of Massachusetts is a nonprofit trade association comprised of home care agencies.

Prior to her appointment, McInnes served on the board as vice president. She will lead the board’s vision and strategic policy.

“It is an incredible honor to take on the role of Chair of the Board of Directors,” McInnes said in a press release. “What the Home Care Alliance of Massachusetts does each day to promote access to care is extraordinary. I look forward to working together with the executive team as we advocate for patients and families in our state amidst the current health care challenges.”

Axxess names new chief operating officer

Axxess has named Tom Codd its chief operating officer.

In his new role, Codd will take the helm of the company’s global operations and will be responsible for driving continued growth.

“Tom joined Axxess two years ago as our first chief people officer and has done exceptional work growing our talent and ensuring we maintain our award-winning culture as we expand,” John Olajide, founder and CEO of Axxess, said in a press release. “His extensive leadership experience and years managing global activities has been invaluable to our growth. As he transitions into his new role, we are excited about the continued positive impact he will have on our ambitious plans.”

Axxess is a home-based care technology company that provides agencies with cloud-based software solutions. The Dallas-based company works with over 9,000 organizations that serve more than 5 million patients around the world.

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In May, the company opened two new locations in Kentucky and Indiana, and the plan is to open up more locations in short order. As of right now, it has 14 locations spanning coast to coast, located in California, Illinois, Indiana, Kentucky, Ohio, South Carolina, Florida and New Jersey.

PACE is a community-based care model, generally for dual-eligible beneficiaries. PACE operators take the full risk of care for their members, and provide an all-encompassing set of services, including traditional home-based care services – either themselves or through partnerships.

The model was incredibly successful during the COVID-19 pandemic, keeping seniors far safer than their skilled nursing facility (SNF) counterparts.

“I think there’s a lot of similarities [between PACE] and where hospice was in the ‘80s,” Russell Hilliard, the chief growth officer of BoldAge PACE, told Home Health Care News’ sister site Hospice News. “It feels like that’s where PACE was a few years ago, and now PACE is expanding quite rapidly. Now I would say PACE is more where hospice was in the ‘90s. People are still generally unaware of what PACE is, although it’s expanding. It’s now available in 34 states, which is remarkable. This year saw several states expand PACE services, but not all states offer it yet.”

Hilliard was at AccentCare – one of the largest home health organizations in the country – for nearly 17 years. There, he was the SVP of market expansion initiatives.

With PACE, there’s plenty of room for market expansion, but at the same time, growth can be stubborn. Though successful, the model is not universally known yet, and the Centers for Medicare & Medicaid Services (CMS) has a rigorous process for approval.

Currently, there are 163 PACE organizations operating more than 300 centers, according to the National PACE Association. There are nearly 76,000 PACE participants across the country.

“Most older adults want to be at home for as long as possible, if not until the very end of their lives, and be as independent with a high quality of life for as long as possible,” Hilliard said. “That’s exactly what PACE aims to do. It’s aligned with what Americans want in their older years. It also aligns with cost savings, because when we keep people at home, it is less expensive than routine ambulance visits to the emergency department and ICU stays that might be preventable. And it puts the horse in front of the cart because it really encourages us also as the payer to make sure we’re using a preventive model.”

Other leaders at BoldAge include: Principal and Founder Todd Stern, the former CEO of Seasons Hospice & Palliative Care, which merged with AccentCare in 2020; Founder and Operating Principal Daniel Czermak, the founder of Acute Health Systems and Beacon of Life; and CEO Mary Austin, who has over 15 years of PACE experience.

Home health and hospice providers have found success working as partners to PACE providers, but they also have opened programs of their own. For instance, the post-acute provider Alivia Care has launched PACE centers as a way to wean itself off of fee-for-service reliance.

BoldAge provides home health care, and also contracts with providers.

“Most of the care that is needed from a home health perspective is often provided by the PACE provider,” Hilliard said. “Perhaps their needs go beyond what we have the ability to do, and in that case, we would contract with a home health agency, but it’s all included.”

Growth can also be more difficult in PACE given the necessary upfront costs.

While taking on the risk of the patient can be a more sustainable model for operators long term, the capital required to get things on the right track is considerable.

“It’s quite different than hospice and home health in that regard, because we have to build the center. And the center also has to include the clinic,” Hilliard said. “So you’re talking about a medical clinic and something that looks very similar to an adult day care center, and you need about 20,000 square feet.”

Over the next couple of years, BoldAge plans to continue expanding its reach. As it does, one of the aspects of the model its leaders are most enjoying is the ability to provide the right care – at the right place, at the right time – to patients without having to jump through hoops with payers.

“PACE doesn’t provide those hoops for them to go through,” Hilliard said. “Rather, they empower the practitioner to say, ‘You want a lot of physical therapy for Betty Smith? No problem, set it up.’”

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Specifically dubbed Habitat Health, Kaiser and Town Hall Ventures will begin building out the program in California in 2025 – in Sacramento and Los Angeles.

“Our dedication to helping improve the health of our communities and members includes ensuring that people covered by Medicaid and Medicare can count on receiving the care and coordination that Kaiser Permanente delivers to our members,” Bechara Choucair, chief health officer at Kaiser Permanente, said in a statement. “By combining our expertise in integrated care with Town Hall Ventures’ experience launching businesses that support underserved communities, Habitat Health will help ensure that people who need the most care have access to high-quality, equitable medical care and services as they continue to age well in the communities that have cared for and supported them.”

Traditionally, PACE programs care for dual-eligible individuals in communities. Providers of the model take on full risk and responsibility for their patients, partnering with other home- and community-based providers on the way.

PACE has gained popularity since the height of the COVID-19 pandemic, when it performed very well in comparison to nursing homes and other settings. There are about 160 PACE organizations currently operating in 32 states and the District of Columbia.

Many experts see it as a model ripe for expansion.

Kaiser and Town Hall Ventures hope to be a leader in the space, aiming to become a “national provider rooted in local partnerships.”

“This new partnership intends to improve the care and quality of life for the growing number of Americans who need it most,” Maria Ansari, CEO and executive director of The Permanente Medical Group, said in a statement. “Kaiser Permanente members who choose to join Habitat Health will receive continuity of care through PACE centers and in their home, beginning in Sacramento.”

While Kaiser is one of the largest medical groups in the country – as well as a large payer – Town Hall Ventures has plenty of home-based care experience itself.

Previously, it has backed Signify Health, Curana Health, Landmark Health, HarmonyCares and a slew of other home-focused organizations.

“We have an extraordinary challenge in this country,” Andy Slavitt, general partner at Town Hall Ventures, said in a statement. “The number of people age 85 and older in our country will double by 2040. We need a better answer for the millions of older adults that is more humane, compassionate, scalable, and affordable for the nation. We share Kaiser Permanente’s commitment to finding innovative ways to improve community health, especially for underserved populations who need it most.”

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Specifically, the bill creates a new adult day center licensure exclusion in order to authorize the Department of Community Health to establish and implement PACE in Georgia as part of the state’s medical assistance program. The Department of Community Health would manage the program.

“When Gov. Kemp signs this legislation, Georgia will become the next state in the country to recognize the value that PACE brings to our elderly community by allowing them to live in their own homes, fully cared for, without needing to move into a nursing home,” Shawn Bloom, president and CEO of the National PACE Association, told Home Health Care News. “PACE is on a path of rapid expansion and growth as more and more states and communities recognize the benefits of this model of care. PACE now serves more than 72,000 people and we expect many more over the coming decade as barriers to access are lifted.”

Access to PACE services have been proven to be effective at keeping seniors healthy, and allowing them to remain in their communities.

“Embedded in this model is that the PACE program also addresses the social determinants of health for the enrollees and wraps around this care with a very comprehensive interdisciplinary care team,” Jade Gong, founder and principal of consulting firm Jade Gong & Associates, previously told HHCN.

During the height of the pandemic, The national PACE COVID-19 death rate was 3.8%, compared to 11.8% in nursing homes. WelbeHealth — a Menlo Park, California-based PACE organization — was even able to achieve a COVID-19 death rate of 2.4%.

“There’s a 24% lower hospitalization rate amongst PACE members compared to dually eligible beneficiaries who receive their care in nursing homes,” Dr. Michael Le, CMO at WelbeHealth, previously told HHCN. “People receiving care through PACE programs are also less likely to be readmitted to the hospital or suffer emergency room visits. All of this significantly reduces the likelihood of being admitted to a nursing home and all the complications that arise from being in a health care setting unnecessarily.”

Despite this, adoption of the PACE model across the country has been stunted.

Some of the reasons for this are the federal red tape that PACE operators face, as well as the high costs associated with setting up shop.

Currently, there are only 159 PACE organizations operating in 32 states and the District of Columbia.

Now, House Bill 1078 is awaiting review from Gov. Brian Kemp.

If signed by the governor, the Department of Community Health will submit a proposal to the Centers for Medicare & Medicaid Services (CMS) regarding reimbursement rates for providers. Following its approval, the department will issue out bids and contracts to providers in order to create PACE centers.

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Like other care models that primarily serve seniors, the Program of All-Inclusive Care for the Elderly (PACE) has achieved a higher profile following the height of the pandemic.

However, there’s still a larger push to expand PACE across the U.S. Currently, there are only 156 PACE organizations operating in 32 states and the District of Columbia.

One of the loudest voices behind this larger push is the National PACE Association.

Beyond geographic PACE expansion, the National PACE Association also sees a future where the model evolves to reach a larger demographic of seniors, including those that fall outside of the category of Medicaid-eligible.

Traditionally, PACE cares for dual-eligible seniors in a given community.

“We refer to them as Medicare-only. I think there’s a substantial opportunity to really position ourselves as a provider of choice for those individuals that increasingly want to stay at home,” Shawn Bloom, president and CEO of the National PACE Association, said during a recent conversation with Home Health Care News.

During the conversation, Bloom also went into detail about other ways he can see PACE potentially evolving, as well as how he is seeing programs work closely with home-based care providers.

HHCN: Looking back over the past few years, how would you describe the overall progress PACE has seen in the U.S.? Are there any defining moments you’d like to highlight?

Bloom: It’s probably important to begin with the point that, for the greater part of 20-plus years, we’ve recognized the potential that PACE could have in the way of supporting older adults’ ability to live in the community.

We have been very strategically focused on supporting, what we refer to as, expanded access to PACE, which is not only growing new programs, but supporting the growth of existing programs. The progress that we’re excited about the most is probably just what we’re beginning to see as unprecedented growth of PACE.

Over the years, we’ve put in place a variety of different strategies to really support the growth of PACE, but the pandemic really changed the perceptions of states. States are in a very prominent role of determining what services are available to older adults in their states, due to Medicaid payments and the Medicaid long-term care system. We’ve seen a significant shift at the state level, and the we’ve seen a lot of attention at the federal level of really incentivizing states to expand the footprint of community-based, non-institutional options. I think between federal policy and state policy, and obviously changing consumer opinions about what services they would find to be most preferential for them, we’re really seeing a wonderful opportunity to expand access to PACE.

There’s really not one single thing, I think it was the confluence of some very favorable factors. We are beginning to get a lot more attention by the press. There’s an old adage that once you’re exposed to PACE, you really fall in love with its potential. We’re beginning to see a lot of expanded recognition that creates a very positive tailwind for us, with respect to consumers that have expanded awareness, and also with state and federal policymakers.

In your view, what are some things that need to happen in order to further accelerate PACE implementation across the country?

I’d say 90% of people that are currently served by PACE are eligible for Medicaid. These are individuals that are in need of long-term care services, so they have significant need for support and health care services, but they also tend to be very low income.

If you look at the demographics in this country, the vast majority of people that need long-term care are not Medicaid eligible. They have some means by which to fund their own care. It may not be for a lengthy period of time, but at least initially.

I think one of the most important things that could happen to accelerate access to PACE would be to address some legislation that we have pending on Capitol Hill, relating to the Medicare Part D prescription drug premium. In PACE, right now the premium is very high, in some ways to reflect the kind of disproportionate degree of needs and medical complexity of those that we serve.

But we are proposing in the legislation that we want to allow individuals that are in the community, before they enroll in PACE, to bring their existing Part D coverage in, which is a fraction of the cost of what it would cost in PACE.

If we did that, we believe that PACE could really emerge as more of a mainstream long-term care option to individuals other than those eligible for Medicaid.

Along these lines, what things are on the National PACE Association’s legislative wishlist for 2024?

I would put it in probably two different buckets.

We do have legislation pending, it’s called the Part D Choice Act. That’s bipartisan supported legislation and has been introduced in both the House and the Senate. It would accomplish essentially what I mentioned before. It would allow individuals to bring their existing Part D coverage with them. On average, for most older adults, it is roughly $50 to $100 a month, compared to $900 to $1,000 a month when accessed through PACE.

The second one is essentially a package of legislation that’s coming together that would help to address some of what we see as some of the more technical policy barriers standing in the way of growing PACE.

What are some of the key issues the National PACE Association is rallying around this year?

At the state level, we’re really working on cultivating opportunities to open up new states. A lot of people can really relate to PACE when they see it, so we want to continue to expand opportunities to cultivate positive awareness. Those are the two biggest ones externally.

Internally, we’re really trying to support the PACE community to continue to put in place internal quality improvement activities. This is a model of care that’s known for yielding unprecedented outcomes. We’re very good at delivering care with a high degree of satisfaction. We are constantly putting in place new projects and new initiatives to help PACE programs further those efforts.

What are some of the main ways PACE providers should be collaborating with home-based care organizations to help keep seniors healthy?

We do collaborate with external organizations and community-based service providers. For example, we might contract out with hospice agencies for end-of-life care for individuals that have very significant end-of-life care needs.

Another point worth making is, the vast majority of our programs are sponsored by existing health care providers. They run the gamut from hospital systems to long-term care systems. In some cases, they’re area agencies on aging, and in other cases, they’re referred to as FQHCs, or federally qualified health clinics.

I think in the context of PACE, there’s a lot of collaboration and a lot of integration with those sponsor services, as I call them. A good example is FQHCs, which play a very important role of providing primary care to typically low income individuals. Those FQHC sponsors of PACE, often, will identify people that really need more than just a primary care visit. They really need the supplemental wraparound comprehensive services that PACE provides, and we will collaborate with them for referrals.

Are there any organizations that are really excelling at collaborating with home-based care providers that you’d like to highlight? What are some of the things these organizations are doing?

It is worth noting as well, that a number of our programs are sponsored by a community collaboration. I’m thinking of a program in Michigan that’s sponsored by the local hospital. Think of sponsors as individuals that kind of own and operate the program. Another sponsor in this Michigan market is an area agency on aging. There’s a home care agency, and then there’s a long-term care provider. There’s an enormous amount of collaboration between and among all those entities in support of PACE.

In general, what are the biggest opportunities you’re seeing for PACE organizations?

I think in our view, vision, and certainly our hopes, plans and actions, we’re really attempting to create opportunities for PACE to serve expanded types of older adults. I mentioned those that are not Medicaid-eligible, we refer to them as Medicare-only. I think there’s a substantial opportunity to really position ourselves as a provider of choice for those individuals that increasingly want to stay at home. From an economic standpoint, we’re less expensive than a nursing home, yet you can stay home. I think being able to be more of a front of mind community-based service option for individuals that are not Medicaid eligible is a huge opportunity for us.

I also think that the other category is new populations, and while Medicare-only falls into that, there are other categories of individuals that are, either under age 55, which is our current enrollment requirement, or individuals that may not yet be eligible for long-term care, but are very medically complex, and really could benefit from PACE.

The third is a little bit abstract. With PACE programs now, once you are deemed as long-term care eligible, which every state has their own criteria, you can access PACE. If you think about it, there’s kind of a closed context of PACE, in terms of who we serve. I think there’s beginning to be a growing ambition among PACE to really unbundle some of those services and bring them out into the community for individuals that are not yet eligible for, but yet could benefit from some degree of support.

People don’t arbitrarily wake up one day and find themselves long-term care eligible, they have a progression of service needs that escalate. During that phase, I think we have a lot to offer, short of the full PACE benefit. We refer to that as building a PACE service pathway. Those are the three things I’d love to see take shape over the next decade or two.

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Now, it’s still on that journey, but much further along. The company’s story is one of promise, one that shows home-based care providers can become risk-bearing entities that have a larger control of their financial futures.

“We really believe that that’s going to be the way that you succeed financially,” Ponder-Stansel told Home Health Care News. “And, also, how you succeed in being able to deliver better outcomes to seriously ill patients.”

The Jacksonville, Florida-based Alivia Care provides home health care, hospice care, personal care, palliative care, advanced care planning and other services across Northern Florida and Southern Georgia. The company has its own Program of All-Inclusive Care for the Elderly (PACE), and plans to open another in due time.

Ponder-Stansel sat down with HHCN and its sister site, Hospice News, to chat about that value-based care journey – and more – last month at Home Care 100 in Scottsdale, Arizona.

The conversation is below, edited for length and clarity.

HHCN: What are your company’s biggest focuses for 2024?

Ponder-Stansel: What we’re really focusing on is standing up value-based care.

We really want to be behind those at-risk physicians in those REACH ACOs, or working with them and figuring out how to be a partner. We’ve been preparing for this for years, that’s what we’ve been doing. And it’s a big opportunity.

So, you’re looking for the best at-risk partners?

That’s right, and we’re also already at risk through our PACE program.

But we’d like to partner with them. We really believe that that’s going to be the way that you succeed financially. And, also how you succeed in being able to deliver better outcomes to seriously ill patients.

And I think that when you’re in any kind of value-based situation, you do need all the components – the private-duty, the Medicare-certified hospice, adult day care, all parts of that care.

Take PACE, for example. It’s a longitudinal service, there’s many mature programs that have had their participants for 10 or 15 years. You’re managing them to keep them in the community and out of long-term care. Now, they may go into long-term care intermittently after a hospitalization, but they’re not custodial. They’re not living there.

You need different tools to do that.

Now, the challenges are that there’s so much consolidation, and so many big companies with a lot of PE investment. We’re a nonprofit regional, so you’re always weighing and balancing how fast you can get your solution to the market without having to merge or take on additional capital. But so far, we haven’t had to go that route.

With some of the cuts coming to home health, and the costs of labor, we’re seeing some margin compression. So we know that the fee-for-service business is probably not going to get us where we want to go.

On the other side of that coin, with value-based reimbursement, there can be lower reimbursement rates there, too. How do you offset that?

It depends on which value-based program, because there’s so many flavors of that.

In PACE, for example. In Florida, Medicaid rates are terrible. That’s why we haven’t had much competition in PACE down there.

But these are dual eligibles. So for almost all of these, you’re looking at their HCC scores. You’re getting your monthly payment – your per member per month – based on their acuity, and then it’s up to you to manage everything, whether it’s a heart transplant or dental care.

That’s the point that I like about it, Special Needs Plans and D-SNPs and the I-SNPS, you get that bucket of money and you get to make decisions based on patient needs without going back for pre-authorization.

It is upside and downside risk, and you really have to have some good AI to help you understand who’s in your population and make sure that you’re meeting that need. It’s about recognizing that risk, and not just giving one visit per week, for example.

We learned the hard way on PACE, and finally have a margin there. It’s year four. If you can manage PACE – because you’re basically a health plan at that point – it really is the best way to manage people with advanced and chronic illnesses.

How specifically are you using AI? Is it table stakes moving forward?

Yes, I think you have to be invested in it. And you have to be intentional about what you need it to do for you.

And part of the challenge is getting the data quick enough.

We want to really be able to stratify risk and create a patient profile. There are certain algorithms that you can develop to say, “Okay, when these particular things happen, you need an extra visit, you probably need to do a med rec.” Because all those things downstream help prevent that rehospitalization, help prevent that adverse outcome. So that’s what we’re looking at.

With the type of risk- and value-based care success you’ve now achieved, does success now beget success, in that you have the proof to show off?

Yes. That was deliberate on our part to do PACE first, because it’s a program that has a structure, a payment system that serves the population we wanted to serve.

We figured if we were going to jump in, we should learn how to do that. And that was a really good decision on our part.

But you have to have a certain scale and the capital to be able to do that in the first place.

This movement toward these at-risk relationships seems kind of necessary to survive in today’s environment. Are you excited about that opportunity? Or are you more worried about it?

Both, obviously. But I really believe that if we have the funds, and do that good, patient-centered care without having to go ask for things from [third parties], we can help people that have these serious illnesses have better outcomes. And that’s the care that gets me going.

You’ll make some margin if you do it well, too. And that’s necessary, but honestly, if you can create that person-centered care based on what you think is best for the patient and build a better system, I think that’s most important.

Because right now, it’s so transactional and so fragmented. You can look at claims data and see what happens to older adults with serious illnesses. And we all lose when there’s low-value care provided. So there’s an altruistic motive too. Plus, I think we’re going to die if we just stay in fee for service.

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In 2023, PACE enrollment exceeded 70,000 participants and has seen an over 40% growth in enrollment since 2019.

Many home-based care providers have already gotten into PACE. The Jacksonville-based Alivia Care – a home health and hospice provider – has even become a PACE administrator itself.

But, in order for providers to become PACE partners or participants, they have to be as prepared as possible prior to the enrollment process.

“We have really seen increasing competition for RFPs in recent years, which has required organizations to really think ahead and prepare ahead of an RFP release,” Tina Hansen Pickett, managing director of ATI Advisory’s Medicare innovation practice, said during a webinar Tuesday.

Generally, PACE participants live in their respective communities prior to enrollment, but are patents who would qualify for nursing home placement based upon their level of impairment and care needs.

PACE providers offer medical, physical, emotional and social need solutions — much of which is centered around a PACE center. A PACE center is a physical facility in which the program offers an adult day center, a medical clinic, dental and other services.

A PACE provider — like InnovAge, for example, one of the largest PACE providers — will enroll those participants and receive capitated payments from Medicare and Medicaid.

PACE organizations or agencies — including health care providers, insurers or community organizations — may issue an RFP to solicit proposals from potential partners interested in participating in or providing services for the PACE program.

These proposals outline how an organization intends to meet the requirements and objectives outlined in the RFP. The applications include details on the services they will provide, their qualifications and experience, their proposed budget and any other relevant information.

One of the strategies ATI Advisory experts recommend is being enthusiastic about each answer and doing the homework beforehand.

“You have to nail absolutely everything,” Jade Gong, senior advisor with ATI Advisory, said during the webinar. “It’s still very surprising when you look through the applications of those that did win and didn’t win, just the small differences in the applications.”

A provider’s bandwidth and capabilities is another key part of the equation.

“Especially if you’re new to PACE,” Gong said. “It’s very possible that PACE is feasible in your market but not feasible for you. This requires careful consideration. There are many unknowns in this process and there will be many unknowns as you construct your RFP. Especially if you’re new to this, you have to make sure you’re committed and have the appetite for the amount of risk that you’ll be taking on.”

Gong recommended organizations do their own internal pressure test. What would this mean for leadership? What is your risk tolerance as a company?

As PACE expands into more states, there isn’t a lot of concrete evidence that can ensure providers will get a certain reimbursement rate in any given state.

Certain capabilities vary from state to state as well.

“You’re going to have to bring in PACE operational knowledge if you don’t already have it in your organization,” Gong said. “All of the states require various month-by-month startup plans with a lot of detail. When it comes to the provision of services, they’re going to ask you how you would operationalize certain components like network development, transportation and other aspects of the program.”

After becoming an expert in these RFPs, Gong reiterated that the process will force organizations to truly understand their own strengths and — maybe more importantly — their weaknesses.

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