NURSING HOME TRANSITION: IMPLEMENTING THE PROGRAM PROVIDING ASSISTANCE TO CAREGIVERS IN TRANSITION (PACT)
By Robert Newcomer, PhD1 Carrie Griffin Graham, PhD2 Eloise Sotelo, MSW3 Linda Anderson, MSW3 1
Professor, Department of Social & Behavioral Sciences, University of California, San Francisco 2 Assistant Adjunct Professor, Department of Social & Behavioral Sciences, University of California, San Francisco 3 Bureau of Aging & Adult Services,
Corresponding Author Robert Newcomer, PhD 3333 California Street, Suite 455 San Francisco, CA 94118 Phone: 415 476-1408 Fax: 415 476-6552 Email:
[email protected] Running heading: Nursing Home Transition 1
Author’s Note This project reported by this paper was funded by the US Administration on Aging under grant number 90-CG-2564. We would like to acknowledge the PACT program staff: Debbie Card, Grace Hagopian, Mary Schramm, and Georgia Stockton, and Bette Wilgus for their dedication to the PACT program and for their cooperation in helping us document the operational processes and developmental background of the project. The authors are solely responsible for the findings and opinions expressed in this report.
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NURSING HOME TRANSITION: IMPLEMENTING THE PROGRAM PROVIDING ASSISTANCE TO CAREGIVERS IN TRANSITION (PACT) Abstract Objective: PACT is a case management program targeted on nursing home residents and their potential caregivers. It enhances discharge planning and continues case management support for a transitional period following a return to the community. Methods: Chart reviews, and staff, discharge planners, and participants interviews document program accomplishments and challenges. Results: The program received 76 referrals during its initial 24 months of operations, accepting 42. Of these 38 were discharged to the community. The average length of nursing home stay was 79 days. Five of those discharged returned to the nursing home within six months, three others died. Caregivers report satisfaction with the instrumental and emotional assistance. Nursing home cooperation was mixed with 60% of referrals coming from six of the county’s 36 facilities. Discussion: Results suggest the value of enhanced discharge planning, but that more work is needed to development and strengthen the referral base of for the program.
Key words: aged, nursing home, case management
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NURSING HOME TRANSITION: IMPLEMENTING THE PROGRAM PROVIDING ASSISTANCE TO CAREGIVERS IN TRANSITION (PACT) Avoiding inappropriate nursing home admissions is a long standing public policy goal. Case management, in combination with home care services, has been a predominant means to achieve this. Recently, stimulated in part by the U.S, Supreme Court’s 1999 Olmstead v. L.C decision and subsequent federal initiatives, States have begun to also consider methods for facilitating the discharge of those in nursing homes. This responds to the court’s determination that confining individuals in institutions without adequate medical reasons is a form of discrimination that violates the Americans with Disabilities Act (ADA) of 1990. At least 26 states initiated demonstration programs between 2001-2003 intended to facilitate a transition from nursing homes (Fox-Grage, Coleman, Folkemer, 2004). Some focus on the aged or nonaged disabled, others on the developmentally disabled. Interventions vary ranging from those designed to streamline community care waiver processing, providing access to transitional service funds, or coordination with hospital discharge planning to divert institutional placements. Most of these innovations have been contingent on Federal grants (i.e., US Centers for Medicare & Medicaid Services, and the US Administration on Aging). The number of individuals expected to benefit from these efforts ranges from about 200 in Wisconsin to 1200 in Florida. One of the innovative programs is known as “Providing Assistance to Caregivers in Transition” or PACT. This is a broker-type case management program targeted on nursing home residents and their potential caregivers. It includes increasing caregiver knowledge of community services, facilitation of a discharge care plan (e.g., referrals into pre-existing community services, and monitoring of the post-discharge placement), emotional support to the caregiver, and funds for durable medical equipment, home modification, and short-term service assistance.
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Either the nursing home resident or the caregiver must be age 60 or over. This paper describes PACT’s features and the issues affecting its potential success during its initial 24 months of operations. Among these are the factors affecting recruitment, enrollment, and participant and staff perceptions about the value of program participation. Background There is a substantial literature tracking from the 1980’s evaluating case management programs for their ability to influence the likelihood of nursing home placement. While many programs showed improvements in client and caregiver well-being, satisfaction with services, and other psychological parameters, they generally failed to reduce nursing home use, or to produce net cost reductions (Hedrick & Inui, 1986; Kemper, Applebaum, Brown, Harrigan, 1987; Weissert, Cready, Pawelak, 1988; Fox, Yordi, Newcomer, 2000). Programs that did succeed in reducing use were those (i.e., Program in All-Inclusive Care for the Elderly (PACE) and the Social HMO) which had integrated case management with primary care and acute care systems (Fischer, Green, Goodman, et al, 2003). In spite of the general absence of cost effectiveness, consumer satisfaction and the potential of case managers to promote quality assurance and quality improvement over home care have contributed to sustaining this approach to nursing home admission risk reduction (Kane & Degenholtz, 1997). As a means of constraining the size of and improving the cost-effectiveness of these programs, most attempt to target those thought to be at risk of nursing home placement or certified as eligible for nursing home placement. Predicting those who would truly have entered nursing homes without assistance, however, has proven to be ethically and technically difficult. Further complicating matters from a cost effectiveness point of view is that rates of placement tend to be low and often of short term (e.g., Weissert, et al., 1988). Consequently, the cost of the
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nursing home placements that occur often do not off-set the costs for community-based care. Recognizing the benefits and challenges of the traditional nursing home prevention programs, PACT was designed instead to focus on those who had entered a nursing home, usually after an acute care hospital episode. The objective is to expedite the return back to the community. Two bodies of literature influenced the PACT program. One of these is the studies of the factors known to affect caregivers prior to and subsequent to the nursing home admission of their spouse or family member. Among these are depression, a need for emotional support, and limited understanding of the assistance needs of the caregiver and the problems they might have in the transition to home (e.g., Courts, Barba, Tesh, 2001; Gaugler, Leitsch, Zarit, Pearlin, 2000; Lieberman & Fisher, 2001; Port, Gruber-Baldini, Burton, et al., 2001). PACT was designed with the assumption is that these issues need to be addressed to enable the client to return home. A second literature derives from the practice changes intended to address problems among high risk cases while they are in transitional situations, e.g., moves from hospital to nursing homes, or hospitals to home care. A population based study found that 22% of persons age 65 or over discharged from a hospital have a subsequent health care event, such an emergency room visit, or hospital stay (Murtaugh & Litke, 2002). Similar finding have come from clinical studies going back to the early 1990’s. Among the factors contributing to the incidence of these events are fragmentation in treatment and communications between levels of care, conflicting care recommendations (including medication errors), and patient/caregiver distress (Bours, Ketelaars, Frederiks, Abu-Saad, Wouters, 1998; Parry, Coleman, Smith, Kramer, 2003; Richards & Coast, 2003; Shepperd, Parks, McClaren, Phillips, 2004). Care coordinators (beyond hospital discharge plans) have generally been found to improve the flow of clinical information; and to obtain better clinical outcomes (e.g., reduced
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rates of readmission), improved client/caregiver satisfaction, reduced rates of depression, and to reduce Medicare expenditures. While PACT does not directly connect with medical care, it builds on key elements of this experience to augment nursing home discharge planning and by offering tangible post discharge assistance to caregivers. PACT Program PACT begin in 2001 under a 36 month grant from the US Administration on Aging. The program is conducted by the Aging and Adult Service Bureau (within California’s Contra Costa County Employment and Human Services Department). This section describes the current roles of the PACT team and the services provided. PACT is predominantly a “broker” model of case management. It operates largely by identifying needs and then trying to facilitate access to existing resources. Facilitation includes having the social worker help caregivers apply for programs like Medicaid personal care and home and community-based care. Assistance is also available to educate caregivers about such community resources as respite care, assistive technology, specialized transportation, and support groups. PACT eligibility is limited to (1) applicants where either the potential care recipient and/or the caregiver is age 60 or over, (2) and where the recipient has been in the nursing home for fewer than 90 days. Additionally, (3) the caregiver has to willing and able to provide adequate support. (4) The care recipient has to reside within Contra Costa County and have an eligible caregiver residing within 50 miles. Staff and Roles Program Management Support consists of a division manager (10% time on the project), program supervisor (20% time), a nurse supervisor, and a staff analyst (each 5 hours/week). The program supervisor is a social worker. She attends case conferences involving all new cases, reviews the financial assessment on participants, approves any items purchased under the
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program funds, and provides input about inactivating cases and in decisions about not accepting referrals into the program. Her expertise is supplemented by the Contra Costa County Public Health Nursing supervisor. The key staff are described below. PACT Public Health Nurse. Care planning begins with a public health nurse (50% time) who meets with the potential client (or the caregiver if the applicant has dementia) to conduct an interview and medical chart review. This information identifies health and functional issues that the caregiver will have to meet for a successful transition. Findings and recommendations are presented at a PACT care planning meeting and care planning is transferred to the social worker. The nurse is available for ongoing consultation. Social Worker. The social worker is the only full time position on the project. Her first role is to conduct a preliminary screening of applications to determine if the caregiver and care recipient meet the basic program criteria. This is usually done reviewing the referral form, but it may sometimes involve direct participant contact. The social worker then conducts an in-person assessment of the caregiver in the home setting. This assessment identifies environmental, social, emotional and financial issues that may pose a problem during the care recipient’s transition from the nursing home, and examines the caregiver’s ability to provide care. The assessment and a care plan identifing the potential services and equipment needed to assist the caregiver are presented for discussion at a PACT care planning meeting. Once the client has transitioned out of the nursing home, the social worker assumes the role of case manager. This includes being the primary contact for the caregiver, and providing ongoing emotional support, guidance and assistance with care needs as they arise. Ombudsman. The county’s nursing home ombudsman’s office allocates an Ombudsman for 20 hours weekly as a member of the PACT program. The Ombudsman serves as a primary
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recruiter of PACT participants. This is done by outreach at community fairs and family council meetings, the distribution of program flyers, conversations with potential participants describing the program, and meetings with nursing home discharge planners. At one facility she sits attends discharge planning meetings helping to identify patients appropriate for the program. Independent Living Resources is a community provider with a subcontract to the PACT program. Their primary contributions to the PACT program include: conducting in home assessments (as needed) to determine the need for assistive technology, assist with the purchase; set up and training in the use of assistive technology; and share their expertise in case conference meetings regarding the assistance and community services that can be provided to PACT participants. Representatives from Independent Living Resource attend all case conferences. PACT Services and Financial Assistance Twenty-five of the 42 individuals discharged from nursing homes were referred by PACT to personal care or home health programs. Included with a referral were assistance with the application, advocacy for maximum hours, assistance in locating and hiring home care providers. Other caregiver referrals included: support groups (n=4); local agencies for home modification funds (n=4); assistance like tax line, bill payer services, utility discounts, and handicap transport assistance (n=4); assistance with Medicaid applications (n=5); Meals on Wheels (n=2); friendly visitors programs (n=1); and hospice (n=3). Complementing case management, PACT initially allocated $21,000 annually (currently $35,000) to fund equipment, supplies, and emergency services not otherwise reimbursable under Medicare, Medicaid, or other insurance; or when waiting for payment from other sources would cause an unreasonable delay in meeting an urgent recipient need. Sometimes expenses could be recovered later from Medicare or other sources. Table 1 lists the equipment and services covered
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by PACT. These funds made it possible to solve situational needs (getting a car windshield repaired, providing assistance with property tax to retain access to the house), or obtain assistive devices such as portable bathtubs, commodes, bars and other devices for bathing, or lift chairs. Average expenditures were $1,200 among those getting assistance. Almost a third of the total dollars were expended on ramps and minor living quarters modifications. Short term home care, the second biggest expense, was incurred while on-going care arrangements were pending. Insert Table 1 About Here Methodology The initial concern in the PACT evaluation has been to develop and refine the program model. Later work with assess clinical efficacy and cost utility. The findings reported document the factors affecting participant recruitment, enrollment, and case management. No comparison group was formed during this developmental phase, but subjective impressions of the program were obtained from participants, and other key informants. Data Collection Data collection for the evaluation was in conformance with a research protocol approved by the Committee on Human Research at the University of California, San Francisco (approval number H945-21314). Data were obtained from the following sources. •
PACT Chart review. Applicant characteristics, referral source, and outcomes were obtained from charts of those referred to PACT between May 2002 and December 2003.
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Interviews with nursing home discharge planners. Eight nursing home discharge planners who had made referrals to PACT were contacted. Four agreed to be interviewed, two were no longer working at that nursing home, and two did not return the phone calls. Five non-referring discharge planners were also contacted, one agreed to be interviewed.
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All these interviews were conducted in person at the provider’s nursing home. •
Interviews with hospital discharge planners. Discharge planners from two hospitals in the county had made referrals to PACT. Both were contacted by telephone for an interview. One agreed, the other was no longer working at the hospital. Two discharge planners from the hospitals that had not referrals were also contacted. One participated. Hospital discharge planner interviews were by telephone at the subjects’ request.
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Interviews with Caregivers served by the PACT program. Respondents was recruited by the PACT social worker. Consents were sought and obtained from all 25 PACT participants active in the two months prior to the evaluator interviews. Two thirds were contacted to schedule interviews, 8 completed (2 face to face in the participant’s home the balance, at the participant’s request, over the telephone), 11 others either refused, had no recollection of the program, or did not return two phone calls. Findings The goal of PACT is to assist caregivers in transitioning family members home after a
nursing home placement. This section examines factors contributing to referral and enrollment, and participant perspectives on the program’s contribution to the nursing home transition. Recruitment The PACT program began its participant recruitment efforts working directly with a small number of nursing homes (however, marketing efforts were sometimes county-wide as in newspaper articles, and in presentations to community groups). The targeting of facilities allowed time to build relationships and gain experience working with nursing administrators and discharge planning staff. There was also concern that numerous referrals would overwhelm PACT capacity to conduct assessments and care planning. Over the course of 2003, three
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facilities accounted for almost 40% of 76 referrals. Six facilities (representing 16% of total nursing home beds in the county) accounted for about 60% of the referrals. At least one referral was made for residents in 20 of the county’s 36 facilities. Referrals could come from a number of sources. Family members were the single most prevalent source, followed by nursing home personnel, and the nursing home Ombudsman. All referrals were screened to determine program eligibility, and having a caregiver willing to work with the PACT program staff. Table 2 shows the distribution of referrals by source and the proportion opened as participants. The source of referral was somewhat related to the rate of acceptance into the program, with the Ombudsman and hospital discharge planning referrals being the most likely to be accepted as PACT participants. Sources like family/friend, and community agencies (e.g., Independent Living Resource, in home supportive services, adult protective services) tended to be more evenly divided between those opened or not opened as active PACT clients. Referrals directly from nursing home staff (usually the social worker) had the lowest rate of acceptance. The total number of referrals varied from month to month, averaging about four. Table 2 About Here Recruitment was targeted on new admissions, with applicants having an average of 32 days in the nursing home before the referral. Half the referrals come in less than two weeks after nursing home admission. Only four referrals came after 100 days. The number of individuals who might be interested and could benefit from PACT has not been formally measured. However, about 7,000 individuals are admitted to Contra Costa County nursing homes annually who will be discharged within three months of admission (California Office of Statewide Health Planning & Development, 2003b). Annually about 4,200 of those admitted will have stays of greater than three months. PACT’s 76 referrals represent about 1% of
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the short term admissions and .7% of all admissions. The number of the nursing home admissions meeting PACT’s eligibility criteria of caregiver interest/availability, age, and geographic location is unknown, but it seems likely that PACT staffing capacity would have to increase substantially to accommodate the number of eligible individuals county wide. Facility Characteristics Facilities most cooperative (as measured by four or more referrals) with PACT during the initial 18 months of client enrollment generally had fewer than 70% of their residents who were Medicaid recipients, and had occupancy rates that were about 80% or higher. These also were facilities where the preponderance of all admissions had short lengths of stay (e.g., 80% or more having an LOS of less than 3 months). The county-wide average is about 60% of patients with a LOS of less than 3 months. The facility with the highest number of PACT referrals (15) worked closely with the Ombudsman Program in identifying candidates for referral. In the remaining facilities with four or more PACT referrals, caregivers were the predominant source of referrals (accounting for 14 of 26 referrals). Within these same facilities, there were only 3 referrals from nursing home staff. The balance was from community agencies. Nursing Home Discharge Planners Interviews with five nursing home discharge planners (four of whom have made referrals to PACT) and interviews with PACT staff provide some insight into the factors contributing to the low number of referrals from nursing homes. The seemingly most easily addressed problems are low awareness of the program and lack of understanding among discharge planners about the type of residents PACT can or is willing to serve. Such communication is complicated by turnover among the discharge planning staff--a chronic problem for nursing homes. Among nursing home staff across all facilities in the county, the average staff turnover is 72%, with a
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range from 20% to more than 170%. Facilities most closely cooperating with PACT had about a 70% turnover (California Office of Statewide Health Planning & Development, 2003a). PACT staff offer another perspective on the barriers to communication and collaboration. They sense that the program may threaten some discharge planners because discharge planners may not know their responsibilities, and may be doing a poor job preparing families to transition a care recipient home. Even when the discharge planners work with PACT staff, problems and misunderstandings can arise. Some discharge planners interviewed confirmed these perspectives, although they might characterize the situation as a lack of understanding about the division of labor. “What should the nursing home discharge planners be doing and what should the PACT social worker do in terms of discharge?” To quote one discharge planner: “I only refer very problematic cases to PACT … Because other people in the nursing home don’t like it when PACT comes in … For example, the nurses here have been very involved caring for a certain patient and then the PACT nurse comes in here and reads the charts and they [the nurse] feel like she is second guessing them. She reviews the charts and asks nursing questions. The RNs here are territorial and feel like they are being second guessed ….” Another discharge planner provided insight into a more subtle misunderstanding of the PACT role. As a social worker, making a referral to PACT is reported as being seen within her facility as under cutting the nursing staff. This shapes who is referred to PACT: “… its bad because PACT was called in by a lowly social worker, and worse, one … who is not licensed. The nurses are higher up than the social worker, and it makes it difficult for a social worker like me to call in someone who threatens a
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nurse. Often I don’t call in PACT until after the patient has been transitioned from Medicare to Medicaid because the patient is then no longer getting rehab, no longer high acuity, and the nurses are less involved. At that point it is easier to call in PACT because the nurses have sort of moved on from that patient. I very rarely call in PACT while the patient is still Medicare. By the time I call in PACT, the nurses are ready to have the patient gone and are accepting of anyone who will help with this.” Hospital Discharge Planners Early in the PACT planning consideration was given to working with hospital discharge planners as one source of referrals. Two assumptions were tied to this: (1) that hospital discharge planners could identify patients being discharged to nursing homes for planned short term stays, (2) that the hospital discharge planner would refer these patients to PACT, so they could enter the nursing home as a PACT participant. This recruitment approach was not fully implemented because there was no hospital outreach worker position in the grant. However, there was some informational marketing to hospitals, consisting largely of the PACT Social Worker and Supervisor visiting the hospitals in Contra Costa County and giving presentations to hospital discharge planners. They also left brochures to be given to potential PACT participants. Recognizing that relationships with hospital discharge planners are essentially an untested element in PACT, the evaluation contacted hospital discharge planners to obtain their perspective on the feasibility of an effective relationship with PACT. The most significant barrier they noted was structural, stemming from the incentives in hospital reimbursement and the absence of non-skilled home care benefits in Medicare. Hospitals are reimbursed by Medicare under a diagnosis–related group (DRG) payment system and have long operated by
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trying to discharge patient as soon as possible to retain savings in the capped payment. This riskincentive system has placed discharge planners in an often conflicted role of advocates and utilization review--making sure that patients are discharged at the earliest possible time. A second barrier is that the discharge planners see their primary role as helping people to go home, or obtaining home health services, and only secondarily to finding a nursing home placement. Distinguishing the needs of patients going home versus those going into nursing homes seems a low priority to them. To this point PACT is not viewed by hospital discharge planners as being responsive to their most urgent needs. Less clear is why the discharge planners did not at least communicate information about PACT to patients going to nursing homes Enrollment The vast majority of referrals or applications to PACT were patients admitted to the nursing home following acute health events such as stroke (n=26); hip fracture (n=9); other fractures (n=9); other surgery (n=12); treatment of such conditions as congestive heart failure, pulmonary disease, and renal failure (n=13). The balance was for reasons of dementia or an unspecified “failure to thrive.” The complexity of care required by all PACT applicants, such as complications associated dementia (sometimes a comorbidity with fractures, stroke, or other chronic conditions), the persistence of paralysis following a stroke, or the failure to regain physical functioning following surgery may not be fully documented in the PACT charts, and may be undercounted. Thirty-four of 76 individuals referred to PACT during it’s first 18 months of operations were not accepted as case management clients. Non acceptance occurred for a variety of reasons. Among this group about one-fifth returned home (usually before the PACT assessment could occur). About the same number died in the nursing home (also usually before an assessment could be conducted). Half were either unwilling to work with PACT in trying to
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achieve a discharge or PACT staff determined that the combination of the resident’s condition and the family support system was not sufficient for post-nursing home support. The typical PACT care recipient was female (33 of 42), age 80 or more, with a female caregiver (28 of 42) aged from the mid-50s to mid-60s. Half those accepted into PACT were eligible for Medicaid (21 of 42). Among referrals not accepted as participants there was an even split between male and female caregivers and a gender and Medicaid eligibility distribution among the potential recipients comparable to those in the program. Does PACT Help More Individuals Return Home? As shown in Table 3, the PACT program was relatively successful in helping residents return to community settings and remain there. Of the 38 leaving the nursing home, 30 remained in community settings as of mid-January 2004, 3 died at home or without returning to the nursing home, and 5 were eventually readmitted to a nursing home. Of the 7 individuals referred but who were discharged without becoming a PACT participant, none reentered nursing homes during the post-discharge observation period. Insert Table 3 About Here With the absence a participant enrollment design where referrals were randomly assigned into PACT or usual care, or some other kind of matched sample of prospective clients one cannot be definitive in addressing whether the clients would have been discharged or not without PACT or whether there was an effect on the length of stay in the nursing home or readmission rates. However, preliminary experiences are encouraging. Those accepted into PACT case management had an average of 79 days in the nursing home before being discharged. Only 13 were there longer than 90 days. PACT staff estimate that 14 of the 38 participants returning home would not have done so without their intervention.
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If PACT is successful, what are the means of this success? Earlier, data were shown on the amount and type of services obtained. Here we report two caregiver comments on their perceptions of key elements in their success. These often include a combination of instrumental assistance and emotional support and empowerment. Interviewer “ What services, equipment or outside help would you say has been the most useful in caring for your mother at home?” Respondent: “Just having (PACT SW) help me get all the equipment and everything. And just talking to her, she makes you feel more confident.” “The social worker at the nursing home wouldn’t have done what (PACT SW) did. (PACT SW) came out to the house and helped me figure out what we needed. She said, ‘You need a guardrail there, some bath adjustments here.’ She tried to get us home care. With her expertise she knew what we would need, so I had it all there before mother came home and I wasn’t in the position of having to run out and get something after my mother was home.” Caregiver empowerment is another PACT program goal. It includes increasing the family caregiver’s knowledge about their family member’s situation and of the options and alternatives available. This knowledge is important initially so that informed decisions about possible discharge can be made, and later too in dealing with day to day needs. Once the care plan is in place PACT wants to reduce case management to monthly phone calls from the social worker, and responding to requests for assistance. Some of this assistance is emotional support. “After my father first came home, I talked with [PACT SW] several times a week. She was so helpful and was able to provide me with information that I couldn’t seem to get anywhere else.”
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Interviewer: “What services, equipment or outside help would you say has been the most useful in caring for your mother at home?” Respondent: “The emotional support from [PACT SW].” PACT has not been in operation long enough to measure the number of care recipients who may eventually be readmitted to a nursing home. Not all discharges work out as originally planned, and adjustments may have to be made. Some of these might result in a readmission, others to a change in caregiver, or relocation into supportive housing. The following vignette illustrates the multiple factors that can sometimes be involved: “One case was closed because client’s son who was acting as the caregiver had a substance abuse problem that was not detected until after the care recipient was discharged into his home and his care. The [PACT social worker] found that the son was often incoherent and that there was evidence that he was taking his mother’s pain medication. The [PACT social worker] … referred the case to Adult Protective Services and recommended that the care recipient be readmitted to a nursing home because her home situation was unsafe.” PACT’s Role when Discharge is Not Possible Under the current work plan, PACT does not have an on-going role with the participants it has evaluated but who are unable to be discharged from nursing homes. The PACT public health nurse, however, does counsel and educate the caregiver regarding rights and quality of care issues in the SNF setting. Moreover, the Ombudsman remains involved in the patient, assisting them and advocating for their care in the nursing home. Discussion and Conclusions The PACT program approach has been to target caregivers who have had family member
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enter a nursing home following a hospital stay. The program has been enrolling participants for 18 months and continues to evolve and refine its methods and criteria for participant recruitment, selection, case management, and inactivation. While a small budget is available for emergency assistance and durable medical equipment, the program is structured as a “broker” model of case management. Funding for on-going personal assistance and other ADL/IADL supports relies on the family’s ability to provide or finance this assistance, or that publicly-supported participants will have timely access to other public financed programs. The program has been reasonably successful in working with families to facilitate nursing home discharges and in maintaining the participants in the community. The reported effects on caregivers are consistent with those found in other long term care case management programs: satisfaction with instrumental assistance and appreciation for the emotional support. The extent to which participants would have been discharged or readmitted to nursing homes without PACT assistance cannot be clearly determined given the current program design and the relatively few participants being served. The PACT experience to date is encouraging, but several conclusions or recommendations about further operations can be drawn. First, if it is desired that the program be tested to determine this effectiveness, then a stronger research design and higher enrollment will need to be incorporated into the program operations. Implementation of a randomized control design seems feasible in this context, given the high number of nursing home admissions monthly and the limited staff capacity. However, any experimental or quasiexperimental design will require an increase in program recruitment, case managed participants, and the resources allocated to tracking participant post discharge outcomes. The outcomes tested also affect the feasibility of these designs. For example, limiting the outcome to whether the intervention reduces the length of a nursing home stay or results in a
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discharge within a defined period such as 90-100 days is much more tenable and less expensive than a design that would attempt to comparison of post discharge outcomes like readmission rates, hospital use, mortality. At this early stage of program operations, priority might best go to the issue of whether the enhanced discharge planning provided by PACT is more effective than “usual care” in expediting a discharge. If that proves true, then a second stage evaluation might monitor the post discharge outcomes. On a more immediate level, the determination of when to inactivate or close PACT’s involvement with a participant has not been resolved as yet by the clinical team but the intention is to implement this within 90 days following discharge. In planning PACT it was assumed that complex cases would be transferred to community based case management programs as soon as appropriate, rather than being retained as open PACT participants. The barriers to this process have been noted by PACT staff. Prominent among these is that PACT clients have to meet other program criteria before a transfer can be implemented. Typically, the criteria include being eligible for nursing home placement based on chronic functional limitations. Such criteria may not recognize that salience of post acute assistance in preventing a deterioration of functioning. The inter-relationship between levels of care is often apparent to those needing assistance, but with substantial barriers to assess resulting from differential eligibility and payer sources. A next step of PACT may be to build arrangements with other care management programs so that transitional care can be accommodated to the advantage of the client. Reconsideration of the approaches to recruitment, screening, assessment, and case management also seems warranted. As currently structured PACT operates with its case load constrained by the workload capability of a single staff member. The social worker is responsible for screening participants for eligibility, conducting family assessments, care
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planning, and care management. Unless staffing is expanded by either adding more social workers or reallocating some functions to other current staff (i.e., the public health nurse or occupational therapists), then the maximum number of individuals entering the program in an average month will be constrained by the hours available from a single staff person. Presently, the program screens less than 1% of the county’s annual nursing home admissions; care planning with about half of those screened. The number of clients who can be screened and managed with the current staffing was not fully determined, but the operating costs of this program are sustainable unless strong evidence of off-setting savings can be demonstrated. The average cost for a PACT enrollee is about $4,800 (inclusive of screening and recruitment-related expenses). The number of social work positions appears to be expandable, whether nursing support and supervision hours could remain at their current ratio is less clear. There seems to be the opportunity to expand both referrals and enrollments. Almost half the nursing homes in the county did not make a single referral to the program in the first 18months, and the average from the others was just over two referrals. One cause of this is that nursing home discharge planners make few referrals to the PACT program. This is apparently the result of misunderstandings about the program’s purpose, discharge planner staff turnover, and nursing home concerns about the PACT program monitoring them. All of these issues should be reexamined for how to improve communication. Additionally, consideration could be given to working with others in the nursing homes, such as the MDS coordinators and Directors of Nursing, rather than or in addition to the discharge planners. The Ombudsman role should also be reexamined. If the PACT nurse and/or social worker work directly with the MDS coordinators or director of nursing for referrals, perhaps the Ombudsman can work more directly with patients and their caregivers in fostering referrals.
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In addition to improving communication about the program, it may also be appropriate to give more attention to facilities that have a high proportion of Medicaid reimbursed patients, and/or that have a lower proportion of patients who historically are discharged within 90 days. Facilities with these characteristics were much less likely to use PACT in 2002-03. Finally, looking at the discharge planning and case management resources more broadly than a single demonstration, the question arises as how might the fragmentation of case management be avoided? At this point PACT is a stand alone program connected via referral to community based care providers and service financing. To the extent that the program is successful in returning individuals to the community, nursing home expenditures are shifted from Medicare, Medicaid, and private insurance to private pay programs or to county long term care programs. In a larger sense, any success of PACT operates to save federal and private dollars, but not county dollars. The sustainability of the program will be more likely if a means can be found to save county funds or return some Medicare and private insurance savings to help finance the efforts in this program. Among the means to do this are to phase the PACT functions into the responsibilities of a program like Medicaid personal care or home and community base waiver, and to bill those not eligible for Medicaid for this assistance, and/or to bill Medicare and private insurance for this discharge planning service. A longer range reformulation of tasks and structure would have nursing homes continue to finance discharge planning but to transfer this function out of the nursing home into a freestanding discharge planning program like PACT.
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References Bours, G.J., Ketelaars, C.A., Frederiks, C.M., Abu-Saad, H.H., Wouters, E.F. (1998). The effects of aftercare on chronic patients and frail elderly patients when discharged from hospital: a systematic review. Journal of Advanced Nursing, 27(5):1076-86 California Office of Statewide Health Planning and Development (COSHPD). (2003a). Long Term Care Facility: Financial Fiscal Year Report Files for 2003. Sacramento, CA: COSHPD. California Office of Statewide Health Planning and Development (COSHPD). (2003b). Long Term Care Facility: Utilization Report Files for 2003. Sacramento, CA: COSHPD. Courts, N.F., Barba, R.E., Tesh, A. (2001). Family caregivers’ attitudes toward aging, caregiving, and nursing home placement. Journal of Gerontological Nursing, 27(8):44-52. Fischer, L.R., Green, C.A., Goodman, M.J., Brody, K.K., Aickin, M., Wei, F., Phelps, L.W., Leutz, W. (2003). Community-based care and risk of nursing home placement. Medical Care, 41(12):1407-16. Fox, P., C. Yordi, R. Newcomer. (2000). Lessons learned from the Medicare Alzheimer’s Disease Demonstration. Alzheimer Disease and Related Disorders, 14(2):87-93. Fox-Grage, W., Coleman, B., Folkemer, D. (2004). The State’s Response to the Olmstead Decision: A 2003 Update. Washington, DC: National Conference of State Legislatures. Gaugler, J.E., Leitsch, S.A., Zarit, S.H., Pearlin, L.I. (2000). Caregiver involvement following institutionalization: Effects of preplacement stress. Research on Aging, 22(4):337-359. Hedrick, S.C. & Inui, T.S. (1986). The effectiveness and cost of home care: An information synthesis. Health Services Research, 20(6 Part 2):851-880. Kane, R.A. & Degenholtz, H.D. (1997). Case management as a force for quality assurance and quality improvement in home care. Journal of Aging & Social Policy, 9(4):5-28.
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Kemper, P., Applebaum, R., Harrigan, M. (1987). Community care demonstrations: What have we learned? Health Care Financing Review, 8(4):87-100. Lieberman M.A. & Fisher, L. (2001). The effects of nursing home placement on family caregivers of patients with Alzheimer’s disease. The Gerontologist, 41(6):819-26. Murtaugh, C.M. & Litke, A. (2002). Transitions through post acute and long-term care settings: Patterns of use and outcomes fro a national cohort of elders. Medical Care, 40(3):227-36. Parry, C., Coleman, E.A., Smith, J.D., Frank, J., Kramer, A.M. (2003). The care transition intervention: a patient-centered approach to ensuring effective transfers between sites of geriatric care. Home Health Care Services Quarterly, 22(3):1-17. Port, C.L., Gruber-Baldini, A.L., Burton, L., Baumgarten, M. Hebel, J.R., Zimmerman, S.I., Magaziner, J. (2001). Resident contact with family and friends following nursing home admission. The Gerontologist, 41(5):589-96. Richards, S. & Coast, J. (2003). Interventions to improve access to health and social care after discharge from hospital: a systematic review. Journal of Health Service Research & Policy, 8(3):171-9. Rosenbaum, S. (2000). The Olmstead decision: implications for state health policy. Health Affairs, 22(5):2228-32. Sheppard, S., Parks, J., McClaren, J., Phillips, C. (2004). Discharge planning from hospital to home. Cochrane Library Issue 1 [http://www.update-software.com/cochrane]. Weissert, W.G., Cready, C.M., Pawelak, J.E. (1988). The past and future of home-and community-based long-term care. The Milbank Quarterly, 66(2):309-388
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Table 1: Services and Equipment Purchased by PACT Items Ramp Home care Transportation Home health Bed Lift chair Bathroom DME DME unspecific Kitchen DME Paid taxes Housecleaning Incontinence supplies Car repair Food vouchers Utilities Emergency Alert (1 month) Undergarments Occupational Therapy Evaluation Total
# Recipients 3 7 5 2 4 4 5 2 2 1 2 4 1 1 1 3 3 1 23a
Source: Unpublished PACT Participant Charts a This is an unduplicated count of recipients.
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Total Expenditures 8105 5500 2517 2012 1813 1390 1323 984 900 837 400 333 300 300 250 228 224 200 27,616
Average Expenditures 2702 786 503 1006 453 348 265 492 450 837 200 88 300 300 250 76 75 200 1200
Table 2: Source of PACT Participant Referrals Source of Referrals Caregiver/Friend Nursing Home Ombudsman Rebab Ctr/Hospital ILR/other com agency Total
Number Referrals 26 15 15 7 13 76
PACT Case Mgt Opened 13 5 11 6 7 42
Source: Unpublished PACT Participant Charts
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PACT Case Mgt Not Opened 13 10 4 1 6 34
Table 3: Discharge Status of PACT Program Referrals Referral Outcomes No PACT Case Mgt PACT Case Management
Returned Home 7
Refused PACT 6
Died in NF/Hosp 8
38
Discharge Infeasible 9
Out of County 4
Discharge Pending
34 4
Source: Unpublished PACT Participant Charts
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Total
42
