An effective, efficient elder care program. Providence ElderPlace focuses on maintaining the continuum of care

Providence ElderPlace, Portland, OR, is an innovative long-term care health maintenance organization. The program is a type of integrated delivery network, offering comprehensive benefits and coordinating the delivery of healthcare services in a specific geographic market. Providence ElderPlace is based on the Program for All-Inclusive Care for the Elderly (PACE), which was developed 20 years ago by On Lok Health Services of San Francisco. PACE helps frail elderly persons remain in their homes as long as possible. PACE is financed through an integrated funding pool of Medicare, Medicaid, and private fees. To be eligible for PACE, an individual must be in need of nursing home care but able to live in the community, with support. Providence ElderPlace provides all healthcare, community-based, and long-term care support services from an adult day healthcare setting. Participants usually attend the day center three times a week. When participants are not at the center, a team of workers visit their homes to observe participants and provide personal and chore support services.     

The growing pains of integrated health care for the elderly: lessons from the expansion of PACE

The early success of the demonstration Program of All-Inclusive Care for the Elderly (PACE) led to its designation as a permanent Medicare program in 1997. But the growth in the number of programs and enrollment has lagged and does not meet expectations. This article offers insights into the mechanisms influencing the expansion of PACE, from information obtained in interviews and surveys of administrators, medical directors, and financial officers in 27 PACE programs. Sixteen barriers to expansion were found, including competition, PACE model characteristics, poor understanding of the program among referral sources, and a lack of financing for expansion. This experience offers important lessons for providing integrated health care to the frail elderly.     

Voluntary partial capitation: the Community Nursing Organization Medicare demonstration

In a recently concluded Medicare demonstration, Community Nursing Organizations (CNOs) received capitated payment to provide a subset of Medicare services through a nursing case management delivery system. Demonstration participation was voluntary, both for CNOs and recruited beneficiaries, raising several challenging issues associated with selection. We investigate provider and beneficiary selection, as well as Medicare costs, using multiple evaluation methodologies. We find that CNO enrollment is associated with increased payment by Medicare for CNO-covered services. Results showing CNO enrollees to be more costly to Medicare for non-CNO services are consistent with cost shifting, but could also be accounted for by biased provider selection into the demonstration.     

Evaluating Florida's Medicaid Provider Services Network Demonstration

Research Objective. To evaluate the design, development, and implementation of Florida's Medicaid provider service network (PSN) demonstration, and the implications of that demonstration for subsequent Medicaid Reform in Florida.
Data Sources, Data Collection. Organizational analyses were based on archival and enrollment data obtained from Florida's Medicaid program and the South Florida Community Care Network, as well as key informant interviews. Closely related fiscal analyses utilized Medicaid claims data from March 1999 through October 2001 extracted from the Florida Medicaid Management Information System.
Study Design. The organizational analyses reported here were based on a structured case study research design.
Principal Findings. Almost every aspect of the development of the new organizational form (PSN) took longer and was more difficult than anticipated. Prior organizational experience with insurance functions proved to be an asset. While fiscal analyses indicated that the program saved the state of Florida a significant amount of money, tracking the precise origin of the savings proved to be challenging.
Conclusions. By most standards, the PSN program was observed to meet its stated objectives. Based in part on this conclusion, the state chose to extend the use of PSNs within its 2006 Medicaid Reform initiative.     

Dental Care in Programs of All-Inclusive Care for the Elderly: Organizational Structures and Protocols

ObjectivesThis study uses a national model of community-based long-term services and supports, the Program of All-inclusive Care for the Elderly (PACE), to identify organizational structures and protocols that can facilitate the delivery of dental examinations.DesignWe developed an online survey instrument and conceptual model for this study representing 10 domains believed to characterize a quality PACE dental program.Setting and ParticipantsThe Qualtrics survey was distributed nationally to all 124 PACE programs in the 31 states PACE was available. Respondents in this study represented 35 programs (program response rate = 28.2%) in 23 states (state response rate = 74.2%).MethodsSelected independent variables from each of the 10 domains were tested against the reported delivery of dental examinations variable using the Kendall τ and χ². Twenty-nine programs were included in the final analysis.ResultsMost programs mandated a dental examination within 31–60 days of enrollment (63.6%). Few programs had a dental manual (15.6%) or any quality assurance for dental care (32.3%). A majority of programs (58.8%) stated that they had a protocol for enrollees to receive a cleaning every 6–12 months. Having a system for quality assurance for dental care, protocol for a cleaning every 6–12 months, mandating a comprehensive dental examination and providing preventive dental services onsite with built-in equipment, were all statistically associated with a higher reported delivery of dental examinations.Conclusion and ImplicationsOrganizations providing long-term services and supports, including PACE, can use these identified domains to develop minimal standards to ensure dental care is part of innovative models of community-based long-term services and supports. Implementing these domains can facilitate effective delivery of dental examinations that have the potential to support positive oral health and general health outcomes.     

The impact of S-CHIP enrollment on physician participation in Medicaid in Alabama and Georgia

OBJECTIVE: To assess whether increasing enrollment in State Children's Health Insurance Programs (S-CHIPs) has an impact on the number of office physicians participating in Medicaid and the extent of their participation. Effects are measured for a freestanding S-CHIP program with an open provider panel and an S-CHIP program that uses the state's Medicaid provider panel. DATA SOURCES: Children's Medicaid claims data for primary care services were used to measure physician participation in the program; census and enrollment data were used to describe market area characteristics. Study Design. This is a time series study of communities in two states, measuring physician Medicaid participation quarterly between 1998 and 2001, controlling for changes in community characteristics and children's program enrollment as well as other factors by quarter. DATA COLLECTION/EXTRACTION: Office physician participation is measured by practice site. Claims data are aggregated to the level of the community and reflect the number of limited practice sites, the ratio of Medicaid office sites to the number of primary care physicians in the community as reported by the American Medical Association (AMA), and the mean number of Medicaid office visits made to physician sites in the community in the quarter. FINDINGS: In Alabama, the state with a freestanding S-CHIP program, there is little association between increased S-CHIP enrollment and physician participation in Medicaid. In Georgia, where the same provider network serves both programs, increases in S-CHIP enrollment are associated with a decline in office-based physician participation in Medicaid in urban areas. CONCLUSION: Linkage of S-CHIP and Medicaid programs through the use of the same provider network, in the absence of market conditions that encourage the expansion of the network, can lead to a negative impact on access for Medicaid enrollees.     

Child and Parental Outcomes Following Involvement in a Preventive Intervention: Efficacy of the PACE Program

This study evaluated whether engagement (i.e., attendance and quality of participation) in the Parenting our Children to Excellence (PACE) program predicted positive child and parent outcomes. PACE in an 8-week preventive intervention aimed at parents of preschool children. The study investigated the relation of engagement to outcomes in an ethnically diverse sample of 610 parents and among a subset of those parents at high risk for child maltreatment. Overall results demonstrated that engagement in PACE significantly improved child and parent outcomes at post-assessment and/or one-year follow-up assessment. Results for the high-risk subsample were even stronger as engagement significantly improved almost all of the child and parent outcomes at post-assessment, which continued to significantly improve in the year following program completion. Findings provide support for the efficacy of PACE in improving child and parent outcomes in an ethnically diverse community population and among parents considered at risk for child maltreatment.     

PACE+: interactive communication technology for behavior change in clinical settings

BACKGROUND: Interactive health communication technologies have the potential to eliminate or greatly reduce many of the barriers to delivery of preventive services. This paper describes the process of developing and evaluating interactive health communication programs for primary care settings. We present as examples the Patient-centered Assessment and Counseling for Exercise plus Nutrition (PACE+) programs, designed to promote physical activity and healthy nutrition with adolescents and adults. METHODS: The PACE+ programs use interactive communication technology to screen multiple behaviors, prioritize areas for intervention, and initiate intervention. Patient information is synthesized for ease of use by clinicians. The patient completes the program on a computer in the clinic waiting room before the provider encounter. Acceptability of the program was evaluated with adolescents (n=252), adults (n=285), and their health care providers. RESULTS: The PACE+ programs were developed, evaluated, modified, and re-evaluated. Feasibility testing indicated that a diverse group of adolescents and adults found the PACE+ computer programs acceptable. Modifications to shorten and refine the programs were identified. CONCLUSIONS: Development of interactive health technologies is an iterative process dependent on feedback from intended users and systems of care. Interactive health communication technologies can be incorporated into clinical settings.     

Effects of the Medicare Alzheimer''s Disease Demonstration on the use of community-based services.

STUDY QUESTION: Did the Medicare Alzheimer''s Disease Demonstration with its case management and community service waivers affect the use of community-based long-term care services among people with dementia and their primary caregivers? DATA SOURCES: Baseline and periodic caregiver interviews. Measures include client and caregiver attributes and self-reported service use. STUDY DESIGN: The demonstration randomly assigned voluntary applicants into treatment and control groups. Treatment group cases were eligible for case management and for up to $699 per month in community care benefits. The actual monthly entitlement varied among the eight demonstration communities due to regional cost and inflation adjustments over time. Analyses are for the year after enrollment. DATA COLLECTION: Analyses are of cases surviving six months or more in the community after enrollment (n = 5,209). Cases received baseline and semi-annual assessments. PRINCIPAL FINDINGS: The intervention of case management and community service reimbursement had a strong, consistent, and positive effect on the likelihood of using home care (including homemaker/chore services, personal care services, companion services) and adult day care. Treatment group clients were at least twice as likely as control group clients to be using any of the four community-based services. A similar, but less pervasive effect was achieved with caregiver training and support group participation. Reimbursement provided by the demonstration''s Medicare waiver was generally not sufficient to exceed the level of control group service acquired through private payment. CONCLUSIONS: Reimbursement levels within the demonstration may have enabled more individuals to purchase some services, but they were not sufficient to increase the average level of use over those in the control group. No consistent differences between demonstration models were found in service use likelihood or average use among users.     

Federal employees health program experiences lack of competition in some areas, raising cost concerns for exchange plans

The Affordable Care Act calls for creation of health insurance exchanges designed to provide private health insurance plan choices. The Federal Employees Health Benefits Program is a national model that to some extent resembles the planned exchanges. Both offer plans at the state level but are also overseen by the federal government. We examined the availability of plans and enrollment levels in the Federal Employees Health Benefits Program throughout the United States in 2010. We found that although plans were widely available, enrollment was concentrated in plans owned by just a few organizations, typically Blue Cross/Blue Shield plans. Enrollment was more concentrated in rural areas, which may reflect historical patterns of enrollment or lack of provider networks. Average biweekly premiums for an individual were lowest ($58.48) in counties where competition was extremely high, rising to $65.13 where competition was extremely low. To make certain that coverage sold through exchanges is affordable, policy makers may need to pay attention to areas where there is little plan competition and take steps through risk-adjustment policies or other measures to narrow differences in premiums and out-of-pocket expenses for consumers.     

Medicare preferred provider organization demonstration: plan offerings and beneficiary enrollment

As preferred provider organizations (PPOs) become the dominant model of managed health care in the private sector, policymakers have increasingly viewed PPOs as an attractive option for Medicare. In part to understand how PPOs might operate under the Medicare Program, CMS launched the Medicare PPO demonstration in January 2003. In this article, we examine how PPOs have operated so far under the demonstration, including PPO availability and market entry; premiums, benefits, and beneficiary cost sharing; and enrollment, market share, enrollee characteristics, and disenrollment to date.     

Feasibility and acceptability of a physical activity promotion programme in general practice

BACKGROUND: Physical activity promotion in general practice is advocated though not incorporated into daily practice. Several barriers must be overcome to develop a feasible and acceptable programme. OBJECTIVE: The aim of this study was to conduct a process evaluation of a physical activity promotion programme in general practice (PACE), in which patients visited their provider (GP or practice nurse) twice. METHODS: Process evaluation was conducted by means of telephone-administered, semi-structured interviews with providers and practice assistants. The main topics of the interviews were overall impression of PACE, PACE training, content and usability of the intervention materials, counselling, implementation of the intervention, and opportunities for future use. RESULTS: In the 15 participating general practices, a total of 17 providers and 12 practice assistants were interviewed. The overall impression of the PACE programme was positive. Most providers experienced the provided material and training as helpful. Some problems concerning the number of forms used and patients having difficulties completing the forms were mentioned. Most providers (70.6%) spend 10 min or more discussing PACE during the first consultation. The second consultation mostly was completed within 10 min. Patients overestimating their level of physical activity was mentioned as the main barrier in providing the counselling. PACE was evaluated as suitable for implementation in Dutch general practice, and 60% of the providers actually intended using PACE in the future. CONCLUSION: The PACE programme was evaluated as being both acceptable and feasible in a selection of Dutch general practices. Positive adaptations will be made in order to implement PACE successfully in general practice at a wider scale.     

The Medical Care Advisory Committee for state Medicaid programs: current status and trends.

Each State Medicaid program is required by Federal Regulations to have a Medical Care Advisory Committee ( MCAC ) which includes provider, consumer, and government representatives and which participates in policy development and program administration. Data are presented about the composition of these committees, their structure, the administrative and financial support they receive, and the nature of their activities. It is argued that they can play an important role in policy formulation and implementation, but that they need to be reformed in order to exploit that potential.     

Housing Stability and Recovery Among Chronically Homeless Persons With Co-Occuring Disorders in Washington,DC

Pathways Housing First provides access to housing, support, and treatment services to clients having the most complex needs—persons who have been homeless for at least 5 years and have both a psychiatric disability and substance dependency. In a 2-year Housing and Urban Development-funded demonstration project in Washington, DC, in 2007 and 2008, we observed promising outcomes in housing retention and reductions in psychiatric symptoms, alcohol use, and demand for intensive support services. The program is designed to be fiscally self-sustaining through extant public disability benefits for housing, treatment, and support services. This approach shows strong support for first providing a permanently supported housing solution for chronically homeless and severely disabled individuals in need of housing and treatment of co-occurring disorders.

KEY FINDINGS

• ▪Housing retention of severely disabled and chronically homeless individuals having extensive service needs, each alcohol dependent and homeless for a minimum of 5 years at intake, was 97% in the first year and 84% in the second year.
• ▪Highly distressed individuals showed significant reduction in psychiatric symptoms within the first year of housing, with client-centered housing support and voluntary psychiatric treatment provided as desired by the client.
• ▪Psychiatrically disabled and alcohol-dependent individuals can make significant mental and behavioral health improvements in recovery within a year of housing without abstinence or treatment compliance demands upon enrollment and with voluntary addiction treatment as desired by the client.
• ▪Demand for intensive ACT services was reduced to much less intensive and costly community support services for 14% of clients within 2 years.

Individuals who remain chronically homeless frequently suffer debilitating effects of serious mental illness and addiction. These frequently co-occurring disorders represent an extremely difficult hurdle for individuals to overcome. Typical housing programs demand sobriety and compliance with psychiatric and behavioral treatment as a condition of admission and continued enrollment. A more realistic, compassionate, and effective approach provides housing without such prerequisites and instead provides immediate access to permanent housing with supports as a foundation for recovery.     

Changes in use of health insurance and food assistance programs in medically underserved communities in the era of welfare reform: an urban study

OBJECTIVES: The purpose of this study was to assess changes in health insurance and food assistance enrollment following passage of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996. METHODS: Extant data sources were used to calculate changes in Temporary Assistance for Needy Families (TANF), Medicaid, and Food Stamp program enrollment in medically underserved Manhattan communities after 1996. RESULTS: Dramatic declines in TANF enrollment were accompanied by declines in Food Stamp program enrollment and a deceleration in Medicaid enrollment among several communities. CONCLUSIONS: As the Personal Responsibility and Work Opportunity Reconciliation Act comes up for reauthorization later in 2002, policymakers should revise legislation so that needy families do not lose health insurance or food assistance support.     

Use of Medicare summary notice inserts to generate interest in the Medicare stop smoking program

PURPOSE: Evaluations of outreach strategies that effectively and efficiently reach the senior population often go unreported. The Medicare Stop Smoking Program (MSSP) was a seven-state demonstration project funded by the Centers for Medicare and Medicaid Services. The 1-year recruitment plan for MSSP included a multifaceted paid media campaign; however, enrollment was slower than anticipated. The purpose of this substudy was to test the effects of including envelope-sized advertisement inserts with Medicare Summary Notices (MSNs) as a supplemental recruitment strategy. METHODS: Information obtained from enrollees on where they had learned about the program as well as overall enrollment rates were analyzed and compared with the time periods during which the inserts were included in MSN mailings. RESULTS: Average call volume to the enrollment center increased by 65.7% in Alabama, the pilot state, and by more than 200% in the subsequent demonstration states. Despite the introduction of the MSN inserts late in the recruitment period, 32.2 % of the 7354 total enrollees stated that they learned about the project through the inserts. CONCLUSIONS: This recruitment method is highly recommended as a cost-effective way to reach the senior population.     

Factors Influencing Implementation of a Physical Activity Intervention in Residential Children’s Homes

The Environmental Intervention in Children’s Homes (ENRICH) study was the first published physical activity intervention undertaken in residential children’s homes (RCHs). The study revealed differences in implementation across the homes, which may be a key factor that affects program effectiveness. The purpose of this study was to examine the direct and indirect effects of organizational capacity, provider characteristics, and quality of prevention support system on level of implementation of the ENRICH intervention. This study analyzed the ENRICH process evaluation data collected from 24 RCHs. Bayesian Path analysis was used to examine the direct and indirect effects of organizational capacity, provider characteristics, and quality of prevention support system on level of implementation. Level of implementation across RCHs was variable, ranging from 38 to 97 % (M?=?68.3, SD?=?14.45). Results revealed that organizational capacity and provider characteristics had significant direct associations with level of implementation. Neither direct nor indirect associations between quality of prevention support system and level of implementation reached statistical significance. Conducting formative assessments on organizational capacity and provider characteristics and incorporating such information in implementation planning may increase the likelihood of achieving higher levels of implementation in future studies.     

Budget impact of Medicaid Section 1115 demonstrations for early HIV treatment

A state-transition model of HIV disease was used to project the costs to Medicaid, Medicare, and AIDS Drug Assistance Programs of proposed Section 1115 Medicaid demonstration projects for the early treatment of HIV-infected patients in Georgia and Massachusetts. Neither demonstration project was projected to meet 5-year tests of no increase in Federal spending and in both States average patient costs to all payers were highest in the first year after enrollment. In assessing expanded health care access for patients with chronic diseases, government payers should consider overall budgetary effects and separately analyze costs for each year's enrollees to avoid creating incentives to cap enrollments.     

The Role of Health Care Provider and Partner Decisional Support in Patients’ Cancer Treatment Decision-Making Satisfaction

Cancer patients rely on multiple sources of support when making treatment decisions; however, most research studies examine the influence of health care provider support while the influence of family member support is understudied. The current study fills this gap by examining the influence of health care providers and partners on decision-making satisfaction. In a cross-sectional study via an online Qualtrics panel, we surveyed cancer patients who reported that they had a spouse or romantic partner when making cancer treatment decisions (n = 479). Decisional support was measured using 5-point, single-item scales for emotional support, informational support, informational-advice support, and appraisal support. Decision-making satisfaction was measured using Holmes-Rovner and colleagues’ (1996) Satisfaction With Decision Scale. We conducted a mediated regression analysis to examine treatment decision-making satisfaction for all participants and a moderated mediation analysis to examine treatment satisfaction among those patients offered a clinical trial. Results indicated that partner support significantly and partially mediated the relationship between health care provider support and patients’ decision-making satisfaction but that results did not vary by enrollment in a clinical trial. This study shows how and why decisional support from partners affects communication between health care providers and cancer patients.