Interview with Dr. Marsha Fretwell
By Eva Sage Gordon
Sisyphus: Thanks for joining us Dr. Fretwell. I’ll begin with the most basic question: What is PACE?
Dr. Fretwell: It stands for Program for All-inclusive Care of the Elderly. The PACE programs began 30 years ago. They offer an alternative model to nursing home placement for frail older adults. But the exciting thing, in these times of conflict over health care funding, is a new way to pay for elder care.
Older individuals are often placed in institutions. Sometimes they are unhappy there, and often the costs are a real burden. PACE uses day care center that integrates social services, rehabilitative services, and medical care into a single organization. Its focus is to keep people in the community for as long as possible.
S: How is the funding different from traditional care?
MF: Each PACE program receives a fixed monthly payment and must provide all heath and social services from this. Physicians and others who work with the clients focus on health maintenance and improvement, rather than waiting to respond to illness.
The majority of funding comes from Medicaid and Medicare dollars, so this program aims to serve those who are elderly and poor. This structuring of financial incentives is innovative for the U.S. health care system.
S: You work with the North Carolina PACE program. What can you tell us about the beginnings of PACE in N.C.?
MF: The first PACE program in North Carolina opened in Wilmington in 2008. It has grown to four more sites across the state. Eight additional communities have PACE programs in development.
S: What kind of treatment options do PACE participants have? Who decides what is best for each person?
MF: The PACE program cares for individuals with both psychosocial and medical frailties. The participants and their caregivers become part of an interdisciplinary health care team which, on enrollment to the program and every six months afterwards, reviews a standard set of functional areas (nutrition, emotion, mobility are some of the domains) and the individual’s diagnoses and medications.
This process leads to a Plan of Care. Its goal is to maximize wellness for the participant and minimize stress for family caretakers.
S: What role do diet and exercise play in the care and maintenance of PACE patient health? What options are available on that front?
MF: Every participant exercises daily at the center, either individually with the Physical Therapist, or in balance and strengthening groups, or by riding an exercise bike for 30 minutes a day. Nutrition is part of the plan. In addition, participants have the opportunity for individual and group sessions to help them address emotional issues and patterns.
S: Where do doctor visits and other treatments take place? Is travel involved? Is there a shuttle system offered?
MF: The participant’s primary nursing and physician care are provided in the day center. Primary care nurses work there, communicating with the primary care physician, specialists, families, and with nursing aides who deliver care in the home.
PACE provides daily transportation to the day center and to appointments with specialists. With complex consultations, the primary care RN will accompany them.
S: How might this program interact with government health care spending changes brought by the health care legislation passed last year?
MF: Several themes have emerged from the legislation. The Centers for Medicare and Medicaid have focused on improving quality, reducing costs, and thinking in terms of serving populations rather than fee for services to an individual.
They have also proposed new ways of organizing and reimbursing providers that create accountability and reduce fragmentation as the means of improving care and reducing cost.
Creating Medical or Health Homes that have primary care at the center is currently being facilitated by grants to states from the federal government. PACE programs represent one end of the spectrum of providers who are already embodying these concepts; The Mayo Clinic model of multispecialist/hospital care represents the other end. In the Mayo Clinic Model, large numbers of primary care and specialists are on salary at the Clinic, providing care to a large population. The Clinic receives a fixed reimbursement for an episode of illness and is accountable to Medicare for the outcome.
S: How might the program expand? How much expansion would be good?
MF: PACE programs currently serve 21,000 Medicaid/Medicare funded individuals in 71 sites across the United States. Each site serves between 100-400 people. The Medicaid and Medicare offices would like for us to serve millions more of these “dual eligible” people because they represent a rapidly growing segment and expensive group of patients under the current “fee for service” system.
Much of the success of the PACE program depends on moving participants and their caretakers to a prevention, wellness, home and community based care system from a highly specialized, illness and hospitalization and nursing home placement system.
Our current system of care-fee for service-rewards physicians and hospitals by volume of care delivered, not by quality of outcomes. Patients and families are insulated from the cost of care.
To engage families and patients in moving from illness treatment to prevention and wellness, there must be trust between them and their physicians and other providers. I place trust and empathic relationships at the center of a successful PACE program. Patients and families must focus on wellness, including exercise, nutrition, and addressing emotional and behavioral patterns. This may require a change in their thinking and behavior, just as it does in health care professionals.
Currently, the goal for our PACE programs is to serve 150 participants, using one physician and one nurse practitioner and four primary care nurses. This is the number of individuals cared for in the average nursing home. Expanding centers beyond this size may impair communication and the intimacy required for trust and social support.
Increasing the number of PACE programs (rather than increasing the number of nursing home beds in a community), and linking smaller centers throughout a state by their funding and standard approaches to measuring patient outcomes, may be a better model for expanding the numbers of frail older individuals the program can serve.
S: And finally, why do you advocate for PACE, rather than other frail patient care models? Do you see any way that PACE could be improved?
MF: I advocate for PACE because it is the first health care program model that aligns the incentives for innovation, shared responsibility, high quality and individually appropriate care for everyone involved. Most exciting is the innovation that comes from working from a fixed reimbursement per month, allowing us to create a budgeting process for setting goals and reaching them.
After 30 years in practice, I have found a new source of intellectual challenge: how to help caregivers become more responsible yet less stressed. I, as a physician of frail older adults, have often struggled with difficult, dysfunctional families, but never have I been so motivated to actually get at the root cause of the problems and help families solve them. Part of the problem is that, as a physician, I didn’t have the psychological and social resources available to me. The PACE interdisciplinary team program supports both the physician and families in providing better care.
How to improve PACE? I would like to see less regulation by the state and federal governments. Time spent fulfilling regulatory documentation is time not spent seeing participants. We are at a level of sophistication with assessment measures that we should be able to provide financial statements and outcome reports to fulfill regulatory requirements. Electronic health records should facilitate this process. The direct and quantitative link between an individual’s level of function and the cost of care sustains the motivation toward optimizing each participant’s physical, emotional and cognitive function.
All of this leads me to close with a final statement: the organizing principles of a care system of high quality and sustainable cost are: aligned financial incentives, trusting relationships, and the goal of optimizing the psychosocial and physical function of older individuals and their caregivers. Thank you for this opportunity to share my thoughts on this topic.
S: Thank you, Dr. Fretwell.
Eva Sage Gordon is co-author of The Everything Guide to Writing Children’s Books, 2nd edition, published by Adams Media in 2011. During 2010-11 she has taught high school in Spain and worked on her MFA in Creative Writing degree at Spalding University.