The Program of All-Inclusive Care for the Elderly (PACE) is a community-based alternative to nursing home care for frail elderly who have significant functional and/or cognitive impairments. It is a managed care program that integrates primary and long term care services with acute care. Rapid expansion of the PACE program is anticipated as a result of the Balanced Budget Act of 1997. The innovative care approach adopted by the PACE program holds the promise of higher quality care, better health outcomes and lower costs compared to care offered to frail elderly enrolled in traditional Medicare and Medicaid programs, or managed care programs. Past studies demonstrated that PACE compares favorably with Medicare fee-for-service care. They have also shown that there is significant variation in health outcomes across sites. This suggests that quality of care in PACE could be improved further. The causes for these variations, and the specific program characteristics associated with them, have not been studied to date. The objective of this study is to identify opportunities for improvements by investigating the links between programs' structure, process and risk-adjusted health outcomes. The study will include 26 PACE sites currently in operation. Individual level data about health outcomes and participants' risks at admission will be used to create risk adjusted outcome measures of quality for each site. Four outcome measures will be developed, based on mortality, changes in functional status, changes in self assessed health status and hospitalizations. These data will be linked to site level data that characterize the structure and process of care in each site. Data about structure and process will be obtained from the National PACE database and from surveys and site visits. Structure and process dimensions will include: Participant characteristics, e.g., health and functional status, ethnicity, family support; Providers' characteristics, e.g., staff turn over, specialty mix, measures of team interactions; Organizational characteristics, e.g., relationship with sponsoring organization, risk sharing, maturity of the site; and External environmental influences, e.g., area practice styles, competition. Statistical regression techniques will be used to test hypotheses about the links between structure, process and outcomes. The knowledge gained from this study would have direct bearing on efforts to improve care in PACE programs, as well as implications for other programs serving frail, non-institutionalized elderly.
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