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PACE accelerates into dubious for-profit nursing home avoidance

Nursing home avoidance – the home care wave fits the profile.  So we know that tech-enabled home care has received several infusions of cash lately.  Whether this is an anomaly -- once new-age firms realize that home care consists of difficult and backbreaking labor – or signals a trend, remains to be seen.  The apparent bloom of the home care business opportunity appears to be the inverse of the business gloom in senior housing, as noted in these Chapter 11 filings. These businesses are failing at the same time as nursing home bed capacity is anticipated to become constrained.   As AARP has endlessly repeated, 90% of older adults want to remain in their own homes. Or maybe it is 87%.  But regardless of intent, most will stay because they can’t afford anything else.  

So who will care for the oldest and frailest?  Does the average of 25 hours per week of home care actually work as dementia or other significant health issues kick in?  And what about those with the least income?  Despite the closure of thousands of nursing homes between 2000 and 2009, there are still plenty of them left -- 1.4 million Americans reside in the nation’s approximately 15,654 nursing homes on any given day, and 735,000 live in assisted living.  If their care was good and the price was right, these might be good alternatives, despite society stated (and much-repeated) preferences for living at home – especially for the 46% of women aged 75+ who live alone.

Nursing home avoidance now finds a new(er) front.  The media hates nursing homes, and as a result, so does everybody else. Good ones never make it into the news. The PACE program was another nursing home avoidance tactic (along with Medicaid Waiver/nursing home diversion. Then came 2010 Money Follows the Person idea for moving people OUT of nursing homes – that’s up to a whopping 52,140 enrollees as of 2015). Okay. Back in the day, with the laudable goal of ‘providing comprehensive and intensive social support,’ PACE programs occasionally attempted to use monitoring technology as an assist to the care delivery for frail home-bound.  Did PACE work well?  Apparently not – there are only 40,000 enrollees in PACE programs today. In other words, PACE, had little impact. Was it lack of publicity, lack of for-profit providers, or maybe it was the convoluted qualification and complex service delivery requirement?

Ah, but there’s startup money in nursing home avoidance? Seriously. You can read it with awe. The words ‘for profit’ appeared and a JP Morgan conference whipped up Silicon Valley interest. So in the Times example, an 81-year-old Denver woman with several health issues has care coordinated and provided by a for-profit PACE program. This ‘capped’ program pulls together $76,728 of care per person for those who qualify – 7% (or $5,000) less than care delivered in a nursing home.  For that ‘savings’, they get the equivalent sum of services as nursing homes provide, but supposedly ‘better care than in a nursing home, including dental.'   Now think about the labor required to coordinate: medical and dental care, medications, meals, bathing, housekeeping, health and social needs, plus transportation to and from PACE-covered adult day centers like InnovAge. And while we’re at it, there will be some remote visitation tech potentially tossed in (hence Silicon Valley interest). Does this scale nationally? Or in five years, will we read about the low numbers when the next wave of ‘innovation’ arrives?

When the media looks for an example to fit the story.  So nursing homes have gotten a well-publicized bad rap – abuse by staff, abuse by residents, poor conditions. These stories are especially useful for slash-and-gash TV news programs and thus the elderly still living at home get to see many of them. Then some AARP poll comes along and surveys 50-somethings. It seems as if all ages and walks of life have seen those programs, read the polls, and want to avoid nursing homes as much as possible. That’s even to the point of convoluted programs like new-aged PACE that can leave people just as vulnerable and lonely much of the time in their own homes.  Other alternatives are not really tackled at all. 1) Use the money to ramp up home care hours for those who are actually home-bound. 2) Seriously improve the quality and experience of nursing homes (and the public perception of them). 3) Use the bucket of federal and state money for placement in assisted living communities of all sizes (which are generally private pay and lack nationwide standards and definitions). At least in both of those settings, there could/there would be someone to sit with at dinner.  


Frankly, regardless of for profit or not for profit entities just realize the total disaster that we have the gall to refer to home and community based long term care?  PACE/ON Lok has been around for 40 years and where were/are all of the advocates of this type of care?  Why has this program not obtained critical mass over four decades of studies, reports, documentaries and countless studies done by Gerontology students across the country not to mention so called gerontology physicians or associated academicians?  Yes, millions have been made off of On Lok by foundation program officers, MDs and numerous others who while extolling the virtue of this program did less than nothing to see it become mainstreamed into the fabric of our health care system.  And now as always, let's blame the mean, for profit industry for stepping in.  Where was CMS during pilot after pilot?  Why can't state legislatures front at least some of the hefty start up costs for this type of program? I am more than incredulous that the aging policy and health care industries knew for years that things were going to hit the fan and just talked and wrung their collective hands.  The for profits (who I am skeptical of) can do no worse than what has already been done.  Planning for the future of those who need or will need affordable and accessible home care has been a Joke.  Let's stop trying to place blame on why nothing has been done.  Let's question forty years of inertia. 

Hmmm - participants in the PACE program traditionally had to be nursing home eligible. I can not see a virtual program being viable with this group and their level of care.


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