CASE STUDY: PACE Program Stalled
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Organization/Program Description
The ABC PACE Organization was one of the original PACE Organizations founded under demonstration waivers authorized by Congress in 1987. ABC started with humble beginnings—one small PACE Center serving a maximum capacity of about 110 PACE participants. Census grew very slowly and capacity was not reached until after four years of operation. After being open for approximately three years, ABC opened a second PACE Center on the opposite side of the metro area to attract more participants from that service area. This new center was approximately twice the size as the first with a capacity to serve about 170 total participants. After opening this second location, census grew rapidly, then slowed after six months.
Like most organizations of its kind, this PACE program relied on community outreach and relationship building to market the program. The organization’s marketing budget was very limited. In an attempt to be cost conscience, management decided to use Case Manager/Social Workers for the enrollment function. Thus, the Case Manager/Social Worker’s had the dual responsibility of explaining the benefits of enrolling into the program and facilitating the enrollment process.
The state in which the program was located had a very progressive home- and community-based services (HCBS) waiver program which was case managed by a Single Point of Entry System. Thus, the health care community was very accustomed to the concept of nursing home diversion, or delayed placement through the HCBS program. The state administering agency had expressed concern about the “woodworking effect” coming into play as a result of the existence of PACE in the community. In other words, if a new program was available, people would come out of the “woodwork” to access the new program. Thus, specific barriers were established to help assure that only the appropriate candidates (very frail) were enrolled into the PACE program.
Organizational Challenges
ABC PACE Program faced a number of significant challenges which, over time, would test the viability of the organization. These challenges included:
- Slow or no census growth
- Increasing cost structure
- Revenue approaching deficient coverage resulting in a increasingly negative bottom line
There were a number of factors which contributed to these problems. These factors were both environmentally and internally related. The environment factors included: lack of state administering agency support for the program; lack of integration into the Point of
Single Entry referral process (they actually perceived PACE to be direct competition); barriers to entry into PACE such as eligibility issues (lack of spousal impoverishment protection); and third party visual inspection of each candidate prior to enrollment.
Internally, the program’s infrastructure and incentives around the issue of growth was non-existent. For example, having the Social Workers responsible for the enrollment process presented a conflict with competing priorities—they were so busy serving the needs of the participants already enrolled that they found it difficult to allocate time to enroll new participants. In addition, the PACE enrollment process has historically been labor intensive for current staff on the Interdisciplinary Team. While Social Workers had strong work ethics and were committed to participant care, priorities usually went to serving currently enrolled participants.
The net result was that this program had an excellent reputation – it was considered one of the community’s “best kept secrets” – but census lagged. In fact, this organization ended several operational years with zero net growth.
Solutions Implemented
Listen and Learn
Altitude Edge Consultants met with key staff to develop a thorough understanding of staff perceptions of where the challenges were and ideas about how they felt they could be corrected. It was quickly evident that there were two, conflicting perceptions of the problem itself and little feel about what could be done to correct it. The staff responsible for marketing and outreach of the ABC’s PACE Program expressed frustration about the slow growth. They easily could vocalize who or what was to blame for this problem—the state, no marketing dollars, the “team.” On the other side, the Interdisciplinary Team didn’t actually perceive that there was a problem because their primary responsibility was to serve the participants already enrolled, and they were doing an excellent job at doing just that. Altitude Edge Consultants were then able to identify the key problems and possible courses of action.
Plan of Action
Census growth needs to be the responsibility and priority of everyone in the organization, not just marketing/outreach. It was important that the entire organization tackle this issue with the same “mind.” Altitude Edge staff worked with management to develop a multi-pronged plan that tackled each of the challenges this PACE organization faced.
Communications Plan: A communication effort was implemented to explain to all staff the reasons growth was essential to maintain viability. It had to be understood that everyone in the organization “owned this problem.” Reward systems were designed to align this priority with specific staff that was responsible for the outcome. The overwhelming message was “No growth = No Viability = No one served (No job).” On the other hand, “Vibrant growth = strong viability = Touch the Lives of many more people (more jobs and opportunity).
Staff Training: The staff responsible for marketing and enrollment needed to be increased and the qualifications/training for these positions changed to more of a sales approach mentality. Thus, ratios were established for enrollment staff along with performance standards and compensations systems re-aligned.
Community Outreach: In addressing the community/environmental issues, a multi-prong approach was used. First, it was imperative the ABC PACE Program needed to invest in its future success by developing a well thought out, organized, and funded, marketing plan. They could no longer afford to be consider the community’s “best kept secret.”
The Point of Single Entry Education: The Point of Single Entry system needed to develop an understanding of the benefits of the program and their responsibility to explain the option to all nursing home eligible candidates. Relationship building and strategic alliances were developed with the leadership of both organizations to the point in which ABC was allowed to provide supplemental case managers to the Point of Single Entries to work along side of HCBS Case Managers. It was understood that there was no requirement for referrals, merely an opportunity to create top-of-mind awareness about the availability of PACE in the community.
State Education: The state-related issues were resolved through Altitude Edge Consultants’ relationship building with state staff. Mutual trust grew in the two groups to the point that the administering agency was able to understand the cost/benefit of discontinuing the “on-site” inspection of each new candidate to PACE. The statistics showed that over the number of years of operation, not one candidate was denied enrollment into PACE due to not meeting functional eligibility requirements. The spousal impoverishment issue required the gentle use of federal law preemptive powers over state laws. The state administering agency was required to come into compliance, thus, state legislation was easily supported.
Outcomes
After years of hard work by all staff of ABC, the challenges were overcome, one by one with the support of Altitude Edge Consultant staff. The census began to grow and ABC was in a position of assuring their viability for the future, becoming one of the fastest growing PACE organizations in the country. They eventually built five additional PACE Centers in the community and were able to touch the lives of over 1,000 participants with the service-rich PACE Program.
Note: This case study represents factual events in which AEC staff played a key role in analyzing, problem solving, and implementing. The names have been changed to preserve anonymity.
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