1. The Elderhaus PACE Program in North Carolina: Improving Functional Outcomes and
Reducing Cost of Care: Preliminary Data
Marsha D. Fretwell, MD1
, Jane S. Old, MSN1
, Kay Zwan BS1
, Kiran Simhadri MS2
1
Elderhaus PACE, Wilmington, North Carolina
2
Mediture, Eden Prairie, Minnesota
Corresponding author:
Marsha D. Fretwell, MD
Elderhaus PACE - Administration
2222 S. 17th Street
Wilmington, North Carolina 28401
T: 910-343-8209
F: 910-343-8836
Email: marsha.fretwell@elderhaus.com

2. Abstract:
The Program of All-inclusive Care for the Elderly (PACE) is at a crossroads in its evolution
as a community based alternative to institutionally based nursing home care. Because of their
perceived value and cost savings to Medicaid and Medicare, PACE Programs are under
increasing pressure to expand the numbers of individuals served by PACE Programs while
simultaneously reducing the overall cost of care. During the first five years of operations, the
Elderhaus PACE Program in Wilmington, North Carolina has demonstrated reduced utilization of
both acute hospital care and skilled nursing home care while demonstrating that 46% of their
participants improved and 20% of the participants maintained their level of functional
independence. We propose that utilization of a Plan of Care Organized by Standard Domains of
Function and the Quantifiable Method to Document Improvement in Functional Health
Outcomes represent a critical factor in our improved outcomes despite lower utilization of
costly hospital and institutional care. The next step will be to disseminate the Plan of Care
process to other PACE Programs and measure its impact on their participants’ functional
outcomes and cost of care. This step is facilitated by the fact that the majority of the PACE
Programs in North Carolina are using the Electronic Medical Record Mediture which has the
Standard Domains and Quantitative Functional Measures imbedded into the software.
Benchmarks for service utilization data are already being collected and will be compared to
service utilization following the implementation of the Plan of Care process.

3. Background:
The National PACE Model PACE is a Medicare/Medicaid managed care benefit for frail
adults aged 55 and older, who, though certified by the State as nursing home eligible, chose to
live in the community. The PACE model features comprehensive medical and social services,
integrated and coordinated by an interdisciplinary team through an adult day health center and
supplemented by in-home and referral services. (1). Enrollees must be able to live safely at
home within a PACE program’s geographic area. Each enrollee receives an interdisciplinary
assessment and care plan on admission and every six months. Each Program establishes their
own assessment tools and process for creating care plans. While all are monitored by
Medicare, there is no common or standard assessment tool or care plan format.
PACE became a Medicare provider and a state Medicaid option under the Balanced
Budget Act of 1997. Monthly capitation payments from Medicare and Medicaid provide
revenue for PACE. At the end of 2013, there were 104 approved PACE programs in 31 states
covering 71,000 participants. In response to perceived value and cost savings, there is
increasing pressure to expand the numbers of individuals enrolled in PACE. Despite this
perception, existing PACE sites continue to experience challenges as they try to deliver cost-
effective care to their targeted population of frail individuals. (2).
The North Carolina PACE Model In 2004, the North Carolina Legislature mandated
creation of two pilot PACE programs. This legislation provided the funds to the Department of
Health and Human Services, Division of Medical Assistance, to secure actuarial analysis for the
capitation rate for North Carolina and added PACE to the North Carolina Medicaid State Plan in

4. 2007. Since 2008, six additional programs have opened in North Carolina and three more are
scheduled to open in 2014. Finally, there two more sites likely to open in the northeastern area
of the state. These PACE programs currently serve more than 1000 individuals (3).
METHODS
Description of the Elderhaus PACE Model
Elderhaus PACE developed from an existing Day Care Center that has operated in Wilmington
for 25 years. In 2008, early enrollment focused on participants from the existing Day Care
Center, recruitment from the practices of two local geriatricians and hospital and skilled nursing
home discharge planners. The heart and soul of Elderhaus PACE is the Interdisciplinary Team
(IDT) which includes: a primary care provider, nurse, social worker, physical therapist,
occupational therapist, recreational therapist or activity coordinator, dietitian, PACE center
Supervisor, nursing assistants, homecare coordinator and drivers. This IDT integrates all
discipline specific assessments, creates options for treatments, acknowledges each participant’s
preferences for care, and is responsible for allocating resources, coordinating all services, and
evaluating outcomes for participants whether their care is based in the home, hospital or long
term care facilities. The product of this process is a comprehensive care plan. Every care plan
meeting is scheduled to include the participants and families to engage them in the creation of
the care plan.
All medical care and social support at Elderhaus PACE is oriented toward achieving and
maintaining each participant’s functional independence, rather than waiting for and treating
acute medical illnesses and thus having to provide an ever increasing amount of compensatory

5. support services. To this end, our Day Center has become a PACE FITNESS (Functional
Independence Through Nurturing Environments and Supportive Services) Center that focuses
on physical, cognitive, emotional and spiritual stimulation and improvement.
At Elderhaus, the Enrollment and every 6 month Plan of Care is organized by Standard
Domains of Biopsychosocial Function within which all of the participant’s problems can be
organized. These Domains of Function are derived from the biology of aging as being most
clinically relevant to improving the health and functional outcomes of frail older adults. These
Domains include: Diagnoses and Medications, Nutrition, Swallowing, Bowel and Bladder
function, Cognition, Emotion, Social Activity, Spirituality, Mobility, Activities of Daily Living, and
Cooperation with the Plan of Care.
Organizing the IDT care planning process around Biopsychosocial Function grew out of a
research project evaluating the effectiveness of Comprehensive Geriatric Assessment in the
acute care hospital (4). Rather than having the different disciplines involved in the care planning
use standardized assessments, the care plan structure was standardized to insure that each of
the study patients received a consistent intervention (5). In 436 patients, all medical or surgical
problems could be organized by their influence on a separate domain of function. The
biopsychosocial functional orientation was Influenced by the work of Drs. George Engel (6) and
Sidney Katz (7), the first establishing that it was necessary to consider multiple dimensions of
human biology i.e., biopsychosocial when determining the health of individuals and the second
demonstrating that Activities of Daily Living functional outcomes of individuals were dependent
on the integration of these three major dimensions of human biology.

6. Finally, at the time of Enrollment and the every 6 month Plan of Care, the IDT uses a
Quantifiable Method to Document Baseline and Improvement in Functional Health Outcome.
They assess each of the Standard Domains of Biopsychosocial Function with a one to six
assessment score, with one assigned to having no functional dependency and six representing
complete functional dependency in that Domain.
* After establishing a Baseline Assessment Score, the IDT, at the same Care Plan,
assign a Predicted Outcome Score based on the discussion of the individualized
intervention planned.
* Six (6) months later, a third assessment score is given which represents both the
Actual Outcome Score achieved from the previous Care Plan interventions and the
Baseline Assessment Score for the next 6 month Care Plan
Using these three data points, clinicians can evaluate the efficiency and effectiveness of
their interventions, their success in setting and achieving appropriate functional goals for our
participants, and demonstrate whether or not there are specific Domains of function that are
problematic for the IDT. This process of assessing, predicting, intervening and evaluating
outcomes is based on the Deming model of improving quality known as the “continuous
improvement” or Plan, Do, Study, Act (8). Acknowledging that other programs and individual
disciplines have utilized functional assessments in planning care and outcomes, it is the
establishment of improving and maintaining function as the major goal of the care, the
organization of the medical diagnoses within the Functional Domains of Care and the

7. application of continuous functional measurement within clinical care that makes this approach
unique.
These quantitative functional measures can also be used to identify high risk patients, to
distribute personal care hours, and help to document that utilization of services is related to
the functional capacity of the individuals and the needs of the caregivers. One Domain that is
critical to evaluating the effectiveness of the IDT care planning process is that titled:
Cooperation with Care Plan. Under this domain, the participant and family are assessed as to
the level of cooperation or compliance with the goals and interventions of the Care Plan. If, as
hoped for, every intervention is discussed with participant and family and their preferences are
respected, Cooperation with Care Plan should be no problem.
RESULTS
Progress to Date and Results:
The Elderhaus PACE Program has been operating since April 2008. Approximately three to six
individuals have been enrolled monthly since that date. Our census increased slowly over the
first three years and at the five year mark in April 2013, was 120 individuals. Description of the
socioeconomic, demographic, clinical and functional characteristics are listed in Table 1. A
comparison of service utilization by Elderhaus PACE with other PACE Programs of similar census
size, years of operation and location in a small city is shown in Table 2. This grouping of
Elderhaus with its “peer” programs attempts to control for the possibility that these three
variables influence participant experience and outcomes. These comparability data are

8. provided by DataPACE2 which is a National Pace Association managed web-based data
warehouse and benchmarking service for PACE organizations.
Discussion:
The Program of All-inclusive Care for the Elderly (PACE) is at a crossroads in its evolution
as a community based alternative to institutionally based nursing home care. By integrating the
Medicare and Medicaid reimbursements into a monthly risk based payment per participant,
PACE programs can effectively integrate the medical care and social support services into a
comprehensive care plan that is individualized to participant and family caregivers needs.
Demonstrating that this can be done in a cost-effective way remains a challenge.
By our focus on participant function, we are creating outcomes relevant to all four of
our stakeholders. For the participant and family caregiver, increased functional independence
supports their remaining in the community and reduces the stress of care for the care givers.
For the IDT and program staff, it promotes a common language for interdisciplinary
communication and keeps them focused on what is important to individual participants. For the
Program Administrators, increased functional independence leads to reduced costs of care and
finally, for the payers (Centers for Medicare and Medicaid Services and State Medicaid Funds),
the focus on functional outcomes addresses their concern for patient centered, integrated care
and also provides a systematic way of measuring outcomes.
In the comparison of Elderhaus PACE’s utilization of services and spending with other
PACE programs of comparable size, we note an increased utilization of Days of Center

9. Attendance , Social Work visits, Primary Care visits, Physical and Occupational Therapy visits
and a reduced utilization of ED visits, Hospital Admissions and Permanent Nursing Home
Placement. We have had five All Cause Re-Admissions over the last five years. Functional
improvement was noted in 46% of participants and functional maintenance in an additional
20% of the participants. There was a linear and inverse relationship between a participant’s
functional outcomes and their utilization of specialists, ERs, hospital care and SNFs. The IDT
achieved Predicted Outcomes in 70% of the Domains of Function (9). Bearing in mind the lack
of specific matching with peer PACE Programs, our data can only suggest that Elderhaus PACE is
providing more social, physical function and primary care support while spending less on
specialty and acute hospital care. Further investigation is necessary to substantiate these data
and to demonstrate that the functionally oriented, continuous improvement structure of the
care plan process is the meaningful intervention.
During this time of rapid expansion of PACE sites in North Carolina and nationally,
modifications of the basic elements of the Model of Care are being considered in order to
facilitate the expansion of numbers of PACE sites and numbers of individuals enrolled in
individual sites. We are proposing that orienting all services to optimizing functional
independence of the participant will improve functional outcomes at a lower cost.
We propose to further evaluate the impact of the Plan of Care Organized by Standard
Domains of Function and the Quantifiable Method to Document Improvement in Functional
Health Outcomes on participant functional outcomes and utilization of acute hospital days. It is
this portion of the overall intervention which, we believe, qualifies as an “Innovative Geriatric
Practice Model”. Our approach will be to engage the other PACE Programs in the State of

10. North Carolina in a project designed to demonstrate whether the application of the Plan of Care
Organized by Standard Domains of Function and the Quantifiable Method to Document
improvement in Functional Health Outcomes would reduce their current rates of acute hospital
care and permanent nursing home placement.
This process is facilitated by having 9 of the 10 programs already utilizing Truchart from
the electronic participant record Mediture. Within Truchart, there is provision for listing all
medical diagnoses alphabetically in the Lifeplan and for documenting a complete care plan in
an electronic form called the Care Plan Review. Elderhaus collaborated with Mediture to
embed the Functional Measures Scoring System within the Care Plan Review form and to add
the Standard functional domains to the Lifeplan, organizing the medical diagnosis under the
functional domain that diagnosis is most likely to impact. (See Appendix 1, 2, 3)
After six months of preparation, each Program will begin to organize their Care
Plans by the Functional Domains and will collect their baseline and predicted outcome functional
assessments as participants 6 month Care Plan come due. For the purposes of the study, we will
collect Functional Measures Score every three months, while maintaining the every six month
care plan routine for at least 12 months. Each Program would serve as their own control, looking
at utilization data in the year proceeding initiation of this new Care Plan process. Through their
mandated Quality Management Program, programs are already collecting the Socioeconomic,
Demographic and Clinical Characteristics and the Service Utilization. Comparisons of Utilization
are available to the programs from DataPACE2 of the National PACE Association.
This project not only shifts the focus of care to improving and maintaining individual
functional independence, it offers a powerful resource of clinically relevant and quantifiable

11. data to support the use of resources while caring for frail older participants. In this time of
financial austerity, there is constant pressure on clinicians to do more with less resources, i.e.,
increase the volume of individuals cared for by a given number of professionals or to reduce
days of attendance in the day center. Given the frailty of our participants, that approach is
unlikely to improve value and reduce costs of care. We propose another approach to creating
high quality care at a sustainable cost: shift the focus from post illness care to care that works
continuously to prevent acute illnesses and thereby improves and maintains the functional
independence of each participant.

12. ACKNOWLEDGMENTS
The authors thank Amy Porter for data support.
Conflict of Interest Disclosures:
Elements of
Financial/Personal
Conflicts
*Author 1
MDF
Author 2
JO
Author 3
KZ
Author 4
KS
Yes No Yes No Yes No Yes No
Employment or Affiliation X X X X
Grants/Funds X X X X
Honoraria X X X X
Speaker Forum X X X X
Consultant X X X X
Stocks X X X X
Royalties X X X X
Expert Testimony X X X X
Board Member X X X X
Patents X X X X

13. Personal Relationship X X X X
*Authors can be listed by abbreviations of their names.
For “yes” x mark(s): give brief explanation below:
KS – Employed by Mediture, the electronic medical record system that is mentioned in the
article.
Author Contributions:
During the design and implementation of care planning, Fretwell, Old and Zwan were
employees of Elderhaus PACE as Medical Director and Center Manager. There is no outside
funding. Marsha Fretwell: Conception and design, analysis and interpretation of data, drafting
the article and final approval. Jane Old: Conception and design, acquisition of data, analysis and
interpretation of data, drafting the article and final approval. Kay Zwan Analysis and
interpretation of data and final approval. Kiran Simhadri: Analysis and interpretation of data
and final approval. The contents are solely the responsibility of the Authors and there are no
known conflicts of interest.
Sponsor’s Role:
There is no sponsor for this project

14. REFERENCES
1. Centers for Medicare and Medicaid Services. PACE fact sheet.
https://www.cms.gov/PACE/Downloads/PACEFactSheet.pdf. Accessed May 19, 2014.
2. Sloan PD, Oudenhoven MD, Broyles I, et al. Challenges to cost-effective care of older
adults with multiple chronic conditions: Perspectives of Program of All-inclusive Care for
the elderly medical directors. J Am Geriatr Soc. 2014; 62:564-565.
3. Fretwell MD, Old JS. The PACE Program: Home-based Care for nursing home- eligible
individuals. NC Med J. 2010; 2(3):209-211.
4. Fretwell MD, Raymond PM, McGarvey S, et al. The Senior Care Study: a controlled trial
of a consultation/unit based geriatric assessment program in acute care. J Am Geriatr
Soc. 1991; 38:1073-1081.
5. Fretwell, MD. The Frail Elderly: Creating standards of care. In: Spiker B, ed. Quality of
Life Assessments in Clinical Trials. New York: Raven Press, Ltd, 1990, pp 225-235.
6. Engel GL, The clinical application of the biopsychosocial model. A J Psych 1980; 137:535-
544.
7. Katz S. Assessing self-maintenance activities of daily living, mobility and instrumental
activities of daily living. JAMA 1983; 37:721-727.
8. Berwick DM. Continuous improvement as an ideal in health care. Sounding Board, N
Engl J Med 1989; 320(1):53-56.
9. Fretwell MD, Old JS, Zwan K, et al. Functional Measures: Critical elements in the
Financial Strategy of PACE Programs. Presented at the North Carolina PACE Annual
Conference. April 2013.

15. Appendix 11
Functional Assessment Coding Scale
Domains Nutrition & Speech Functional Assessment
Coding Scale (1-6) 1 2 3 4 5 6
Nutrition
BMI 18.5-25 BMI 25..1-27 BMI 27.1-28.9 BMI 29-30 or 17-18.5
BMI >30 - <40 or 17-
18.5
BMI >=30 or <17
Albumin >=3.5 Albumin >=3.3
Albumin > = 3.1-
3.2
Albumin >= 2.9-3.0 Albumin >=2.0-2.8 Albumin > 2.0
Vit B-12 >600
Vit B-12 = 551-
600
Vit B-12 = 501-550 Vit B-12 = 401-500 Vit B-12 = 301-400 Vit B-12<=300
Vit D >= 35 Vit D = 25-34 Vit D = 20-24 Vit D = 15-19 Vit D 10-14 Vit D < 10
HbA1c <=6.0 HbA1c = 6.1- 6.5 HbA1c = 6.6-7.0 HbA1c = 7.1-7.5 HbA1c = 7.6-8.0 HbA1c >8.0
Undesirable Wt %
Change
<3% 3.2-4.9 5.6-6.9 7.0-7.9 8.0-9.0 >10
Swallowing No dysphagia
Hx of dysphagia
without current
symptoms
Some episodes of
choking during last 6
months
Requires constant
cueing to avoid
choking
Dependent on feeding
or gastrostomy tube
No oral intake due
to dysphagia
Domains Primary Care Functional Assessment
Bowels
every 1-3 days;
no clinical
symptoms or
concerns
every 1-3 days;
history of diarrhea
or constipation
every 1-3 days; with
symptoms of
diarrhea or
constipation
> every 3 days
Aware: impacted or
incontinent
Unaware:
impacted or
incontinent
Bladder
Intact,
recognize need
to void
Symptoms of
Frequency or
urgency;
continent with self
- toileting
Occasional accidents
without cueing
Daily accidents despite
cueing. On Toileting
Program Q2 hr
Numerous Daily
accidents
Urinary
retention/Catheter
Urinary Tract
Infections/6
months
0-1 2 3 4 5 6
Skin Integrity
Clear; no
lesions
Rashes /Skin
Irritation
Recurrent skin
tears
History of open
wounds, pressure
and non-pressure
Open wound, non-
pressure etiology (DM,
PVD, venous
insufficiency)
Open wound,
pressure etiology
(Decubitus)
2

16. 3

17. Appendix 34
Adding the Target & Predicted Functional Measure Scores5
To the Person Centered Care Plan6
7
8
Abbreviations:9
Prt – Participant10
GDS – Geriatric Depression Scale11
SW – Social Worker12
IDT – Interdisciplinary Team13
Domain
Problem
Predicted FMS
Current FMS

18. Table I. Demographic, Socioeconomic, Clinical and Functional Characteristics of the Elderhaus PACE14
Population – 2013 Average Census 127.315
Characteristic Value
Demographic %
A. Age (average age 78.6),
55-64 14
65-74 25
75-85 30
>85 31
B. Gender %
Male 26
Female 74
C. Ethnicity %
White 50
Black 47
Hispanic 2
Asian/Pacific Indian 1
D. Living Arrangements %
Permanent Placement 5.5
Community Living 94.5
E. Insurance Status %
Dual Eligible 96.0
Medicare Only 1.4

19. Medicaid Only 2.6
F. Diagnosis %
Dementia 94
Chronic Obstructive Pulmonary Disease 23
Congestive Heart Failure 25
Diabetes 46
Chronic Kidney Disease 37
Cerebral Vascular Event 42
Vascular Disease 19
G. Advanced Directives %
MOST a
Form Completed 98
1. Longevity (Full Scope) 32
2. Function (Limited) 57
3. Comfort Care 9
H. Death Rate, % in 5 Years 29
I. Site of Death %
Home 23.8
Skilled Nursing & Assisted Living Facilities 57.1
Hospice Care Center 0.48
Hospital 14.3
16

20. J. Functional Domains Average Scoreb
Cognition - Attention 3.6
Cognition – Short Term Memory 3.0
Emotion 2.5
Social/Activities 2.2
Spiritually 2.7
Cooperation with Care Plan 2.6
Mobility 2.0
Activity of Daily Living 2.1
Footnotes:17
a
MOST Form: Medical Orders for Scope of Treatment – Advanced Directives for State of North Carolina,18
b
Average Functional Measures Scores in Standard Domains of Function, Data Represents Results from Last19
Assessment - Range is 1 to 6, with 1 = Highest Function and 6 = Lowest Function.20

21. Table II. Comparison of Service Utilization of Elderhaus PACE and “Peer” PACE Programs of Comparable21
Census Size, Years of Operation and Geographic Location (small city vs rural or urban):22
23
Characteristic Value Value
Service Utilization - Average of past 4 Quarters Elderhaus PACE PMPM Peer PMPM
Emergency Department Visits 0.2 0.6
Skilled Permanent Placement (Long Term) 1.6 2.5
Skilled Rehabilitative Placement (Short Term) 0.5 0.5
Specialty Referrals 0.5 1.0
Physical and Occupational Therapy Encounters 7.4 3.9
Attendance to Day Center 15.7 8.4
Social Worker Encounters 2.4 1.3
Primary Care Encounters 2.9 1.2
Hospital Rate Elderhaus PACE PMPA Peer PMPA
Acute Hospital Admissions 0.2 0.6
24
25
26
Abbreviations:27
PMPM = Per Member Per Month, PMPA = Per Member Per Annum28
29