and hospice regulations, and facilitating difficult conversations. They also attend biweekly patient-centered conferences.
An early evaluation of the program found that AIM program patients had higher rates of hospice utilization (Ciemins et al., 2006). Notably, the program was successful in increasing hospice utilization by African Americans, a group that has traditionally had very low rates of hospice use.
In addition to private-sector initiatives, a number of models have been tested by the Centers for Medicare and Medicaid Services (CMS). These demonstration projects have examined mechanisms to restructure the Medicare and Medicaid programs in ways that support more efficient and more effective care delivery for older adults. For example, older adults with long-term health care needs often face fragmentation in their care because the Medicare program finances acute care at the national level while state-administered Medicaid programs are the predominant payers for long-term care services (Kaiser Family Foundation, 2006). Discontinuities between the two programs can translate into discontinuities in care as well as into higher costs, as the two programs often seek to shift costs to each other (National Commission for Quality Long Term Care, 2006). CMS demonstration projects have tested a number of ways to improve quality in Medicare (and often Medicaid as well). Several of these projects are described below.
PACE is a managed-care program that was developed to address the spectrum of needs for adults aged 55 and older with disability levels that make them eligible for nursing-home care (Tritz, 2005). The program is based on the belief that the well-being of older adults can be improved by serving them in the community (Mukamel et al., 2007). PACE was modeled after an innovative initiative in San Francisco, On Lok, that was designed to help the Asian American community care for older adults in their homes (Greenwood, 2001).
Start-up funds for PACE were provided by private foundations, and its implementation was supported by congressional authorization of Medicare and Medicaid waivers (Gross et al., 2004). The PACE model funds a comprehensive set of services by combining federal Medicare dollars, state and federal Medicaid funds, and the individuals’ own contributions (National PACE Association, 2007). The PACE service package includes all Medicare and Medicaid covered services plus additional services, including adult day care, nutritional counseling, recreational therapy, transportation, and personal-care services, such as meals at home (CMS, 2005). PACE also pays for nursing-home care, if appropriate.