Some patients among the aging population hit social and economic barriers to quality hospice care.

This is according to Dr. Eric Reines, chief medical officer at Element Care Program of All-Inclusive Care for the Elderly (PACE), and Linda Gauvain, registered nurse and director of PACE care service at the same organization. They told Hospice News that today’s seniors require an interdisciplinary approach that addresses the wide range of needs.

Massachusetts-based Element Care’s PACE programs have increasingly focused on addressing the largest social determinants of health needs among low-income senior populations. Founded in 1994, the nonprofit health care organization launched its first PACE location in Lynn, Massachusetts, a year later. Element Care PACE recently expanded with a de novo in that same town.

Hospice News recently sat down with Reines and Gauvain to talk about the ways their organization is working to meet patients’ diverse medical and nonmedical needs.

How large of a role do social determinants of health play in driving health care utilization at the end of life?

Social determinants of health such as socioeconomic status and where people live, work and age play a large role in driving health care utilization and ultimately influence health outcomes.

Poorer health outcomes and higher risk of premature death are intrinsically linked with poverty. It’s important for seniors to have access to programs that can help address social determinants of health, such as the Medicare and Medicaid-funded PACE.

PACE programs streamline health care for older adults by bringing all medical care under one roof, including interdisciplinary care teams, an emphasized focus on preventive medicine and a commitment to personalized attention. PACE helps reduce barriers to care and offers a proactive and person-centered approach to health care, particularly for low-income seniors.

What are the largest unmet psychosocial, physical, emotional and spiritual needs among underserved lower-income seniors?

Historically disadvantaged people tend to mistrust referrals to hospice and palliative care because they have been underserved by medicine in general and sense that they are “being dumped” when these services are suggested. In general, this population also tends to be deeply religious. Religious faith and spirituality must be immediately supported.

Developing trust takes time, requiring frequent interaction and keeping promises.

How can hospices collaborate with PACE providers to fill these gaps of need?

Element Care PACE is actively building partnerships with housing models, such as assisted living facilities, rest homes and senior housing buildings to integrate specialized care. This care would include [health care] provider and nursing visits, behavioral health support, as well as physical and occupational therapies.

As seniors age in place with access to health care models internally, a relationship — and more importantly a trust — is established. When the need for end-of-life care approaches, the foundation of those relationships allow seniors to feel more comfortable and supported during the end of life process.

Interdisciplinary teams within PACE meet regularly to ensure each participant’s comprehensive medical and social needs are met. If teams determine that a participant would benefit from end-of-life care, that would be an appropriate time to engage with a hospice care facility to coordinate next steps.

PACE programs are dedicated to helping older adults live safely and comfortably in their homes and communities for as long as they can, keeping their stays in hospitals and nursing facilities as minimal as possible.

What is important for hospice providers to understand about the ways to bridge disparity gaps among seniors via services such as PACE, caregiver coordination or adult day services?

In today’s fragmented health care landscape the vision of a holistic approach to well-being remains elusive, particularly for seniors grappling with complex medical needs. As the population of seniors continues to grow, so do the challenges they encounter in accessing quality and coordinated health care.

PACE helps play a vital role in bridging disparity gaps for seniors with complex medical needs and serious illnesses that are progressing, who may not be hospice eligible.

The goal of PACE is to keep participants in their own home for as long as possible. However, if at some point it is in the best interest of the participant to receive care in a nursing home or hospice, their PACE interdisciplinary team will help coordinate that care.

Where do you see PACE growth heading in coming years? What are the main factors driving this growth?

Seniors reap the benefits of having their care consolidated through PACE. Not only does it alleviate stress and take off the pressure of managing complex medical care, but there is also a cost benefit to the consolidated care model as well.

Participants who qualify for PACE programs don’t pay for copays, glasses, therapy visits, procedures or any other qualifying medical costs. When necessary, home health visits from nurses, dietitians and physical therapy are also included. PACE empowers seniors to take control of their health and maintain a sense of independence.

What do you think are the important trends taking place in PACE service delivery, and how do you see these impacting seniors as they reach a need for end-of-life care?

According to the U.S. Centers for Disease Control and Prevention (CDC), about 80% of older adults have at least one chronic condition, and 50% have at least two, often requiring complex management and coordination between multiple health care providers.

Unfortunately, statistics from the Journal of the American Geriatrics Society show just 12% of older adults receive coordinated care across different healthcare settings, such as primary care, specialists, hospitals, and home health services, leading to fragmented and inefficient care delivery.

Simplifying medical care is key for older adults who often struggle to juggle appointments ranging from basic wellness and illness visits, to dental, eye and hearing care, to rehabilitation. PACE unified care teams cover the facilitation of all these aspects of medical care, along with screenings, therapy appointments and more.