HOW ADULT FAMILY CARE PROVIDERS CAN WORK WITH THE NATIONAL PACE MODEL

This article was written by Teresa Arnold, the Caregiver Homes Branch Manager for the North Shore area in Massachusetts.

PACE stands for Programs of All-inclusive Care for the Elderly and provides community-based care for people over the age of 55 living with disabilities. PACE provides comprehensive care using Medicare and Medicaid funding to cover medically-necessary services. A participant of PACE can have either Medicaid or Medicare or both to join. The premise of the model is an in interdisciplinary team of professionals who provide the coordinated care needed from primary care, to Physical or Occupational Therapy, Social Work counseling, home care services, prescription drugs, medical transportation and even nursing home stays if necessary and more.

To join PACE, you must be at least 55 years old, live in the PACE service area, assessed as needing nursing home level of care and the ability to live safely in the community with the help of PACE. A goal of PACE, like Caregiver Homes, is to support our clients to safely live in the community for as long as possible.

If a person is a client of Caregiver Homes, they could benefit from the PACE model as well. With Caregiver Homes support for the client and caregiver, PACE could be fitting for direct medical care. With similar missions as community-based providers, our respective staff teams partner to manage client care plans in order to ensure the best level of services for PACE/Caregiver Homes clients.

The Caregiver Homes model of Adult Family Care provides professional Case Management support on a daily basis. Our RNs and Care Managers are seasoned professionals who visit clients monthly- more if needed – and also monitor client status through our own SeniorTouch TM system. Caregivers, which are at the center of Caregiver Homes's unique Structured Family Caregiving model, are required to make daily notes, recording functional status (ADL and IADL). Care team members and other clinical staff –through HIPAA-compliant access are able to monitor the client's health status through daily review of Caregiver notes. The Caregiver Homes team can then share care plan changes with the PACE team to be on the same page with client status.

The collaboration of PACE and Caregiver Homes is an excellent option for PACE participants who have a live-in caregiver, usually a family member, who is dedicated to keeping their loved one at home.