At a time when the patient population is becoming increasingly complex and conversations continue to be had over where clinical care is best provided, ArchCare President and CEO Scott LaRue believes now is the time for the Program of All-Inclusive Care for the Elderly (PACE) to pick up steam.
LaRue has been at the helm of the Archdiocese of New York’s health care system since 2011. In that time he has grown ArchCare’s PACE program from a single site in Harlem to seven PACE centers across New York City and Westchester, and the growth has only been further accelerated by the COVID-19 pandemic.
Skilled Nursing News got a chance to sit down with LaRue to hear about how PACE has grown in the last year, where skilled nursing facilities fit in a post-pandemic world and the biggest challenges they face going forward.
This conversation has been edited for length and clarity.
What are the biggest lessons that you learned from the pandemic?
I would say how fragile the healthcare system is and the logistics of society, the supply chain, and how quickly what we take for granted came unglued.
It really taught you the necessity of being more self-sufficient in terms of emergency preparedness and not relying on traditional governmental entities to be a backstop.
How did ArchCare adapt during the pandemic?
We were more fortunate than most because we’re a large post-acute system. We serve about 9,000 individuals a day and have 4,300 employees. We’ve run the full spectrum from a little over 2,000 nursing home beds to a specialty hospital, a PACE program, a Medicare Advantage program and a number of other programs. We were able to pull resources across traditional programmatic boundaries and treat the pandemic and our response to it in a more tactical way, and allocate the resources that were coming into the system where they were needed most at that time.
That allowed us to have the flexibility or the wherewithal to manage the pandemic in a way that an independent operator could not.
Our approach was it didn’t matter what program you were in, what your job title was, you had to go where we needed to at that moment. And people did it. And thank goodness they did.
Tell me a little bit about the PACE program and what growth you’ve seen from it in this last year.
A program of all-inclusive care (PACE) is for individuals 55 and older who would qualify for nursing home level of care. A PACE program has three key components: an article 28 clinic, a social day program and home care services. Those three components are coordinated with an interdisciplinary care team that is generally about 250 participants to one team. And that team coordinates all the needs of that member, whether they’re social determinants, whether they’re clinical, whether they’re issues that are home physical infrastructure issues. The plan looks at the member, you know, in a very holistic way and comes up with a care plan that allows them to live as independently as possible through the supports of that program.
The pandemic created an environment where consumers and policymakers …are demanding more home and community based services because of their concern about living in an institution. My belief is this transition was already underway, but the pandemic brought it to the forefront and I think it accelerated things by at least 10 years. And these policymakers are like, ‘Jeez I wish there was a program out there that provided the social determinants of health, the clinical care in a home based environment,’ and that’s exactly what PACE does.
I really think this is the moment for PACE. People are willing now to consider clinical services in a home setting that they weren’t necessarily ready to accept before the pandemic.
ArchCare recently entered into two partnerships — one with Ride Health and the other with Montefiore Health System. Can you tell me a little about these partnerships and how that helped grow this program?
Ride Health operates on a platform that would be similar to Uber except it’s on demand rides for people with disabilities or who need assistance getting to and from their appointments.
Not everyone needs an Accessavan, a wheelchair van, or a big bus to go to their doctor’s office. Many people could use a traditional car to do so… and ride health brought the combination of transportation expertise and logistics to a platform that makes it easy for us to schedule and track those transportation visits. It’s just improved the quality of the transportation for the people we serve.
In terms of Montefiore, the Obama administration passed what was called the PACE Innovation Act, and what they were trying to do is take what makes PACE so successful in coordinating and delivering services — and create the way that it could expand through more flexibility — either in the individuals that are served or the regulations around the program.
So our program with Montefiore, what we’re trying to do is use an existing infrastructure that Montefiore already has, whether it’s their own clinic, their own physician network, etc., and rather than rebuilding those in a silo within a PACE program, partnering with that existing infrastructure to expand PACE. It lowers your capital investment and it builds on the success of an organization like Montefiore to bring people into the PACE program.
Do you anticipate there could be more partnerships like this with other health systems or programs of that nature?
PACE is garnering a lot of attention right now. For all the reasons I just mentioned to you, it’s not an easy program to start up from scratch so I think a lot of organizations are looking for existing PACE programs that they can partner with to improve the quality and care for those really challenging high-utilizing dual eligibles that they are seeing frequently in their ERs, their doctors’ offices and their clinics.
Where do you think skilled nursing facilities fit in our post-pandemic world?
Given that ArchCare operates over 2,000 skilled nursing beds here in the metro New York area, I continue to believe that there will always be a role for skilled nursing. There’s always going to be a percent of the population [where] that is the best setting for them. And with 10,000 people, what is it a day, reaching the age of 65, the onslaught of baby boomers that we’ve been talking about for 10 years, these facilities are going to be needed. But they’ve got to be modernized, they’ve got to enhance and improve their clinical skills because the level of people that are going to be served in them are going to be very clinically complex, they already are.
And people are going to demand a higher level of service and expectation than historically. So we’re very focused on modernizing our facilities, partnering with our local hospitals on various clinical programs, academic affiliations. This is not yesterday’s nursing home.
We’ve developed centers for neurodegenerative disease, Huntington’s disease. We’re building a state of the art advanced memory care unit. You know, I think it’s going to be those kinds of niches that you’re going to have to have within your complement of beds to be successful.
What’s next for the PACE program?
We’re completely focused on expanding to meet the consumer demand for that community-based program, and continuing to leverage technology and new creative programs that our hospital partners and physician groups are doing. We just signed a contract with Mount Sinai for paramedics to go to a participant’s home if they believe they’re in need of ER services to do an on-site, immediate evaluation.
It’s going to be a combination of all of these programs that I think it’s going to shake itself out over the next five to 10 years and we’re going to be living in a different world as it relates to community based health care.
With the paramedicine program, could that potentially eliminate the need for patients to go into hospitals in certain situations?
Hopefully it’s going to create an opportunity where we can prevent those avoidable ER visits and hospitalizations and, where appropriate, either add more services in the home or direct the individual to one of our skilled nursing facilities, more complex care units for maybe two to three days, whatever is needed in order to stabilize them.
The contract with the paramedicine group requires them to be at the home within 60 minutes of us making contact with them. So if we have a PACE participant who calls our on-call physician or nurse practitioner and we think that we want to send someone to the home, that’s the quickest way for us to do it is to get a paramedic in the home and evaluate the situation, and then we can modify the plan of care as needed from there.
As a leader in the post-acute space, what keeps you up at night?
Certainly the delta variant keeps me up at night. We’ve seen about a 79% vaccination rate across all the individuals we serve combined between the community and in-patients, and we’re at about 76% for our staff. This still leaves 20 to 25% of the individuals who have chosen not to get vaccinated. And I completely agree with the premise that we’re facing a pandemic of the unvaccinated. We’re not interested in going through this again. We’re really pressing to get people to follow the CDC guidance and get vaccinated.
In a bigger picture way, I’m very focused on the ability of moving a large organization such as ArchCare in the direction that we just talked about and balancing, you know, keeping one foot in the current model, looking forward to the new one, and getting the resources necessary for us to be successful.
The pandemic has created a staffing crisis that I have not seen in my career. The Metro New York area has always been pretty well protected from the staffing issues that the rest of the country is facing but right now staffing is a critical problem across all sectors.
Are there any plans for ArchCare to implement any vaccination requirements or further education?
We’ve been very, very aggressive and I think we’ve had remarkable results through a combination of education and reward. Every program that achieved herd immunity — we defined it as 75% of all the employees of that particular program — once they were vaccinated everybody got $100, so we created some peer pressure to get other individuals and their colleagues to get vaccinated.
And I think we’ve done about everything that we can on the encouragement, education and inducement side. I do believe that we’re now going to be evolving toward a more mandatory situation. I’m not ready to do that yet, but I believe that’s eventually where we’re going to end up.
We have one program that takes care of children and young adults so we have people under 12 who can’t be vaccinated. And in that program we do mandate that everyone working with them has to be vaccinated. We’ve also taken the position that all new employees have to be vaccinated, so we’re not going to exacerbate the current problem of about 20 to 25% of not being vaccinated by hiring more unvaccinated individuals.
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