Assisted Living Facility Use by the Program of All‐Inclusive Care for the Elderly

To the Editor: The primary goal of the Program of All-Inclusive Care for the Elderly (PACE) is to provide a cost-effective, patient-centered, community-based alternative to nursing home care (NH) for a NH-eligible population.1-4 PACE programs are fully capitated and are therefore responsible for all costs associated with health care.2, 3, 5 Safe and supportive housing can be a critical component of achieving that goal. When care needs for an individual are high, PACE programs might consider assisted living facilities (ALFs) and must weigh the advantages and disadvantages of ALFs against the capabilities of providing care at home (with additional support from PACE) or in a NH. Cost of care is an important consideration. In the United States in 2010, the yearly cost of ALFs was $37,572, and the NH cost was $79,935 for a private room.6, 7 ALFs vary in size and staffing model, but provide a monitored and supportive environment that is generally more homelike than NHs, although the skills and expertise typically available in ALFs have been questioned.8, 9 The comprehensive care oversight may mitigate this, and the case management that PACE provides can offload tasks from and provide assistance to ALFs in managing PACE enrollees who reside there. The aim of this study was to identify factors associated with ALF use by one PACE program and to characterize potential advantages and disadvantages of ALF use within the PACE model. This study was conducted at one PACE site—Hopkins Elder Plus (HEP)—in two parts: cross-sectional examination of patient-level data abstracted from charts at HEP to compare characteristics of PACE enrollees who resided in different settings and qualitative content analysis of three PACE staff focus group discussions to improve understanding of factors associated with the use of ALFs for PACE enrollees. One hundred and twenty-six charts (100% of enrollees in November 2010) were abstracted, and participants were categorized according to four residential types: home alone, home with family, ALF, and NH (Table 1). This analysis showed that participants residing in ALFs and NHs were similar to those living at home except that they were older and more functionally dependent, had been enrolled in PACE longer, and as expected, received no home care. The three focus groups consisted of clinical (n = 7), social work and administrative (n = 8), and recreational and transport (n = 7) staff members who had been working at PACE for an average of 8.2 years. Content analysis revealed that the primary determinants of ALF use were safety concerns for participants and impaired health and limited capabilities of home caregivers. PACE staff members cited several specific examples of individuals for whom these concerns were the primary drivers of ALF use. Cost was also mentioned as an important consideration when making housing recommendations (e.g., ALF vs NH), because PACE programs are typically responsible for much of the cost. Staff members noted that they were aware of the cost differences and were careful to ensure that higher levels of care (such as NH) were truly necessary. Discussions about trade-offs (autonomy and quality of life vs safety and assistance) were also part of these discussions, as well as the “home-like” atmosphere of ALFs. ALFs were also being used frequently for a temporary, monitored living situation to meet a short-term need. This happens “a few times per month,” according to focus group members. Factors such as geographic proximity to family also prompted ALF use (over NH) for short-term needs. This mixed-methods study is the first to provide data on issues related to the use of ALFs by a PACE program. Although older and more functionally dependent, participants living in ALFs were otherwise similar to those living at home, suggesting that other factors influence the decision to use ALFs. The quantity and types of services that PACE provides (home care, visits to day care centers) to certain participants could have influenced who was able to stay at home and who needed ALF or NH. The potential advantages of collaboration between ALFs and PACE include the clinical support that PACE provides, which can fill gaps in the capacity of ALFs to care for frail and medically complex residents whom they would otherwise be unable to manage.8-10 Short-term usage for observation and supervised care (with PACE support) is another novel opportunity with potential advantages to the resident, ALFs, and PACE. In summary, ALFs offer the additional resource of continuously supervised residential care, which can work synergistically with the clinical support and care direction of PACE toward the goal of extending care outside of NHs, meeting individual care needs, and providing high-value care. Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: Kohli, Arbaje, Leff, Statom, McNabney: study concept and design, acquisition of subjects and data, analysis and interpretation of data, preparation of manuscript. Sponsor's Role: None.