Using Telehealth to Care for Seniors at Programs for the All-Inclusive Care of the Elderly

The Program for the All-Inclusive Care of the Elderly (PACE) is an effective model that provides wrap-around care via an interdisciplinary team of providers to typically underserved, vulnerable seniors. As of 2021, the PACE model operates in 30 states. There are 139 sponsoring PACE organizations in the US, running 272 PACE centers, serving approximately 55,000, mostly dual-eligible, seniors. PACE uses a wellcoordinated team of staff and providers from the following disciplines: primary care, social work, physical therapy, occupational therapy, nursing, recreation therapy, dietician, home care, transportation, PACE center manager, and personal care. PACE coordinates care across all care settings including specialty care, drugs, transportation, home care, and meals. Participants are transported by PACE an average of 16 trips per month. Nationally, PACE provides almost 22,000 meals every day to participants. Finally, from a clinical standpoint, participants’ average age is 77-years, they have an average of six chronic conditions, six different prescriptions, and almost half of participants have some form of dementia.

Managing such a clinically and socioeconomically complex caseload of seniors is a complicated endeavor. For any PACE organization to become or remain economically sustainable, it must closely monitor operational efficiencies, particularly with respect to its highest expense categories, such as emergency department (ED) and hospital utilization, transportation, and exacerbations of chronic diseases, including mental health disorders. This guide describes new, innovative ways of using telehealth to manage clinical care and the expenses related to these high expense categories with the goal of supporting PACE in providing high-quality care to seniors in a financially sustainable manner. As you read this guide, think about your own PACE program and match the opportunities that are described with your highest priority areas. Deciding which problem(s) you want to solve with telehealth will help you determine which telehealth model you will deploy. At that point, we suggest downloading our implementation guides that more specifically describe implementation steps.

We wish you success on your journey using telehealth to provide high-quality and economically efficient care to your PACE participants.

Sincerely,

Zia Agha, MD & Ross Colt, MD