Providing Behavioral Health Care in PACE - A Review of Federal and State Manual Regulations.

OBJECTIVES: Present analysis of the federal and state regulations that guide The Program of All-Inclusive Care for the Elderly (PACE) operations and core clinical features for direction on behavioral health (BH). DESIGN: Review and synthesize the federal (Centers for Medicare and Medicaid Services [CMS]) and all publicly available state manuals according to the BH-Serious Illness Care (SIC) model domains. SETTING AND PARTICIPANTS: The 155 PACE organizations operating in 32 states and the District of Columbia. METHODS: A multipronged search was conducted to identify official state and federal manuals guiding the implementation and functions of PACE organizations. The CMS PACE website was used to identify the federal PACE manual. State-level manuals for 32 states with PACE programs were identified through several sources, including official PACE websites, contacts through official websites, the National PACE Association (NPA), and public and academic search engines. The manuals were searched according to the BH-SIC model domains that pertain to integrating BH care with complex care individuals. RESULTS: According to the CMS Manual, the interdisciplinary team is responsible for holistic care of PACE enrollees, but a BH specialist is not a required member. The CMS Manual includes information on BH clinical functions, BH workforce, and structures for outcome measurement, quality, and accountability. Eight of 32 PACE-participating states offer publicly available state PACE manuals; of which 3 offer information on BH clinical functions. CONCLUSIONS AND IMPLICATIONS: Regarding BH, federal and state manual regulations establish limited guidance for comprehensive care service delivery at PACE organizations. The absence of clear directives weakens BH care delivery due to a limiting the ability to develop quality measures and accountability structures. This hinders incentivization and accountability to truly all-inclusive care. Clearer guidelines and regulatory parameters regarding BH care at federal and state levels may enable more PACE organizations to meet rising BH demands of aging communities.

Behavioral health integration in the Program of All-Inclusive Care for the Elderly (PACE): A scoping review.

BACKGROUND: The Program of All-inclusive Care for the Elderly (PACE) is a community-based care model that delivers collaborative care via an interdisciplinary team to meet the medical and social needs of older adults eligible for nursing home placement. Fifty-nine percent of PACE participants are reported to have at least one psychiatric disorder. PACE organizations (POs) function through an interdisciplinary model of care, but a behavioral health (BH) provider is not a mandated role on the interdisciplinary team. Published literature regarding how POs integrate and provide BH services is limited; however, the National PACE Association (NPA) and select POs have made significant contributions to behavioral health integration (BHI) efforts in PACE. METHODS: PubMED, EMBASE, and PsycINFO were searched for articles published between January 2000 and June 2022; hand-searching was also conducted. Research articles and items involving BH components or programming in POs were included. Evidence of BH programming and initiatives at the organization and national level was summarized. RESULTS: This review reported on nine primary items addressing BH in POs from 2004 to 2022. It found evidence of successful BH initiatives in PACE and identified a gap of published information given an evident need for BH services in the PACE participant population. Findings also indicate the NPA works to advance BH integration in POs with a dedicated workgroup that has produced the NPA BH Toolkit, BH training webinar series, and a site coaching program. CONCLUSIONS: In the absence of PACE-specific BH delivery guidelines and guidance from the federal or state level for PACE programs, BH service inclusion has been developed unevenly across POs. Assessing the landscape of BH inclusion across POs is a step toward evidence-based and standardized inclusion of BH within the all-inclusive care model.

Value-Based Payment and Behavioral Health.

This Viewpoint discusses behavioral health and its transition to value-based payment models.

Perspectives of Remote Volunteer Palliative Care Consultants During COVID: A Qualitative Study.

CONTEXT: A novel remote volunteer program was implemented in response to the initial COVID-19 surge in New York City, allowing out-of-state palliative care specialists to serve patients and families in need. No study has detailed the perceptions of these consultants. OBJECTIVES: To understand the experiences of remote volunteer palliative care consultants during the initial COVID-19 surge. METHODS: This qualitative study utilized a thematic analysis approach. During January and February 2021, we conducted one-on-one semi-structured interviews with 15 board-certified palliative care physicians who participated in the program. Codes and emerging themes were identified through iterative discussion and comparison. RESULTS: Five overarching themes (with sub-themes in parentheses) were identified: 1) motivations for participating in the program, 2) logistical evaluation of the program (integration, telehealth model, dyad structure and debriefing sessions), 3) barriers to delivery (language and cultural differences, culture of high-intensity care, legal and administrative differences), 4) emotional burden (moral distress, burnout), and 5) ideas for improvements. Notably, participants observed institutional and cultural differences that posed challenges to delivery of care. Many expressed feelings of distress related to the uncertainty and scarcity caused by the pandemic, although volunteering may have been protective against burnout. CONCLUSION: This study provides an in-depth look at the experiences of remote volunteer palliative care consultants during the initial COVID-19 surge from the unique perspectives of the consultants themselves. Participants expressed overall positive and meaningful experiences and felt that the model was appropriate given the circumstances. Additionally, participants provided recommendations that could guide future implementations of similar programs.