By: John Corlett, President and Executive Director
Emily Muttillo, Director of Research, Williamson Family Fellow for Applied Research

Programs for All-inclusive Care for the Elderly (PACE) delivers coordinated care outside of an institution for those requiring a high level of medical and social care to maintain independence. An interdisciplinary team of professionals coordinates the care of individuals enrolled in both Medicaid and Medicare to ensure the participants receive the benefits of a comprehensive system of care. Currently, the only PACE program in Ohio is limited to residents of Cuyahoga County.

In 2022 there have been renewed legislative efforts to expand the PACE program in Ohio.

In 2022 there have been renewed legislative efforts to expand the PACE program in Ohio, including in Lorain County. Ohio House Bill 600 was introduced by State Representative Bill Roemer (R-Richfield) on March 22, 2022. Co-Sponsors include Representatives Jim Hoops, Scott Lipps, Susan Manchester, William Seitz, and Dick Stein.

PACE eligible providers under proposed legislation

Under the legislation, within 90 days of the bill’s effective date, the Ohio Department of Aging must issue a request for proposals (RFP) from entities interested in becoming PACE organizations for service areas in the counties, or contiguous zip codes within the counties, or extending from the counties, of: Franklin, Hamilton, Montgomery, Lorain, Lucas, and Summit.

To be eligible for approval to become a PACE organization, the legislation states an entity must meet all of the following requirements:

• Be, or be owned by, a nonprofit, tax-exempt entity or a for-profit entity;
• Provide a feasibility study of its proposed service area to the Department within 90 days after providing the Department with a letter of intent to apply;
• Have a current, valid Medicaid provider agreement or be eligible to enter into a provider agreement;
• Meet all federal requirements applicable to PACE program providers;
• Have experience providing health care services to frail older adults, and demonstrate that each member of the entity’s staff complies with federal PACE regulations applicable to direct care staff;
• Have a facility suitable to be a PACE center, or plans to acquire, build, or expand a facility suitable to be a PACE center prior to beginning services;
• Any additional requirements established in rules.

Advocates are urging the Ohio General Assembly to pass the legislation and to utilize $50 million in American Rescue Plan Act Funding to finance an expansion of the PACE program in Ohio during the lame duck legislative session scheduled to begin after the November 8 General Election. Advocates are also working closely with the Ohio Department of Aging, and the Ohio Department of Medicaid.

Advocates are also working closely with the Ohio Department of Aging, and the Ohio Department of Medicaid.

If the legislation were to pass during the lame duck legislative session, the Ohio Department of Aging is required to issue an RFP for entities interested in becoming a PACE provider. The department then has another 6 months from when the RFP was issued to determine which entities to approve as PACE providers. After that the U.S. Centers for Medicare and Medicaid Services (CMS) must approve potential PACE entities. What this means is that even if the Ohio General Assembly approves the PACE proposal during the lame duck session it’s not likely that a new program would be up and running before 2024.

Lorain County is well suited for an expansion of the PACE program

Currently, over a quarter of the residents, approximately 76,000 individuals, are aged 60 and older and that number is expected to grow by twenty percent over the next five years. Lorain County Office on Aging conducted a needs assessment in 2021 to gain a better understanding of the needs and desires of those 76,000 older adults. The needs assessment utilized both secondary data from sources including the U.S. Census Bureau’s American Community Survey and primary sources including a randomized survey and focus groups. The needs assessment results indicate both a strong desire of older adults to stay within the county as they age and a high need for additional aging services, particularly those that serve the dual eligible population. In the randomized survey, eighty percent of residents indicated that it is important for them to remain in the county even if they did not remain in their current homes.

Of the approximately 76,000 residents, over a third have a disability.

Of the approximately 76,000 residents, over a third have a disability. Twelve percent of older adults have an independent living difficulty which is defined as having difficulty doing errands alone such as visiting a doctor’s office or shopping because of a physical or mental condition. An additional seven percent have a self-care difficulty meaning they have difficulty bathing or dressing. These types of disability often require a level of care that necessitates another person to provide that care on a regular basis. Thirty percent of residents report they have had a fall one or more times in the past year. Falls can be both an indicator of health conditions that require attention and lead to injury requiring a higher level of care. Currently forty percent of older adults in the county live alone. Older adults with disabilities, chronic conditions or high health needs who either live alone or live with an individual who cannot physically provide care for another person often require the assistance of one or more paid caregiver.

Many older adults have concerns about accessing services to support them as they age, including those that live in Lorain County. Over half of residents indicate they do not want to be placed in a long-term care facility and more than a third worry that people will not think they can take care of themselves.  Just under thirty percent are worried about losing control of their lives. All of these concerns speak to the worries and anxieties that many feel as their health and mobility decline and are unsure of how their care will be coordinated. The very design of PACE eases those anxieties through the patient centered care coordination teams.

Coverage and cost of care

The cost of care is another concern among older adults in Lorain County. More than a third of residents expressed concern about being able to afford medical bills, prescriptions and aging and health related services. Currently, health related expenses, such as prescriptions, health insurance and medical bills are in the top five regular expenses of older adults, topped only by groceries and utilities. For those with limited incomes, paying out of pocket for in home care is not a sustainable option. The median income for older adults in Lorain county is $47,455 and one in seven older adults live in or near poverty. When enrolled in PACE, all of the medical expenses are included. Those who cannot pay for home health yet require a high level of care benefit from PACE programs, but currently only Ohioans who live within Cuyahoga County are eligible to receive that care.

The median income for older adults in Lorain county is $47,455 and one in seven older adults live in or near poverty.

Nearly three fourths of Lorain County residents do not have or are not sure if they have access to transportation for seniors or individuals with disabilities. This makes traveling to and from medical appointments a challenge for those who do not drive or are not able to use the fixed bus route. There is a high need for additional medical transportation to serve those without the ability to drive themselves or access to another mode of transportation. Enrolling in the PACE program provides access to and from medical appointments and to social opportunities within PACE locations.

In order to qualify for PACE, an individual must qualify both financially and clinically. An estimated 1,821 residents of Lorain County would meet the criteria to be enrolled in a PACE program. Nearly half of those eligible live in Elyria and the city of Lorain. With the population of older adults in the county expected to grow by nearly twenty percent in the next five years the estimated number of those eligible for PACE will also grow.  With current publicly funded programming offered through the Lorain County Office on Aging already at capacity, additional programs and services are urgently needed to meet the growing need.

Lorain County leaders welcome a PACE expansion

Local leaders in the aging network of Lorain County would welcome and support a PACE expansion into Lorain County. Lauren Ksiazek, Director of the Lorain County Office on Aging, says she “would be over the moon” if the PACE program could come to Lorain County. Adding “I love the PACE model”. She has visited the McGregor PACE program in Cuyahoga County and talked with its leaders and staff. She admires its comprehensiveness, the socialization it provides, and the coordination of Medicaid and Medicare health benefits.  For example, she points out that there isn’t a single adult day care center in Lorain County. Older adults eligible for Medicaid and Medicare (dual-eligible) stand to gain the most from a PACE program according to Ksiazek. That’s because Lorain County doesn’t have a levy providing funding for older adult services the need for PACE is even greater.

Local leaders in the aging network of Lorain County would welcome and support a PACE expansion into Lorain County.

Barbara Thomas, CEO of Kendal at Oberlin, has visited PACE programs around the country in her role as a national leadership coach for Leading Age. Thomas was always puzzled until recently that Ohio “wasn’t recognizing and expanding the program.” She commented that it would “absolutely a good fit for Lorain County” because of the challenging economic characteristics of the community. Adding it’s a “model program without the walls of a nursing home,” and that the McGregor PACE program “has very low staff turnover because there is a sense of commitment to the people they are serving.”

To gauge the likely uptake of a new medical program for older adults, like PACE, an analysis of the uptake of the Medicare Advantage Plans is useful. Enrollment into Advantage plans has been steadily increasing over the past five years in Lorain County. The current rate of uptake, fifty one percent, is higher than the national and state average. It is nearly as high as Cuyahoga County which has had great success with only existing PACE program in the state. Increased utilization of Advantage plans indicates a willingness of residents to look outside of traditional Medicare and Medicaid programs to organize their medical care.

If House Bill 600 passes in the lame duck legislative session, Lorain County should be prioritized for expansion of the McGregor PACE program.

If House Bill 600 passes in the lame duck legislative session, Lorain County should be prioritized for expansion of the McGregor PACE program. Leadership in agencies that serve older adults in Lorain County are supportive of a PACE expansion and believe it would fill a gap in services older adults indicate they both need and desire. With a growing population and the majority of older residents hoping to remain independent while residing in the county additional programs and services are needed to meet their needs. For those clinically and financially, PACE would provide the answer to many challenges associated with growing older.