D407 Task 1 Client-Focused Care Analysis Example

A Client-Focused Model for a Frail Older Woman Who Keeps Returning to the Emergency Department: How the Program of All-Inclusive Care for the Elderly Would Change Her Care, and the Trends Behind It

Student Name

Leavitt School of Health, Western Governors University

D407: Models of Care and Healthcare Trends, Task 1

Course Instructor

Month Day, Year

A Client-Focused Model for a Frail Older Woman Who Keeps Returning to the Emergency Department: How the Program of All-Inclusive Care for the Elderly Would Change Her Care, and the Trends Behind It

The Client

Mrs. Dolores Whitfield is a composite widow, 79, living by herself in a second-floor apartment. She has heart failure, type 2 diabetes, osteoarthritis of both knees and mild cognitive impairment. She qualifies for both Medicare and Medicaid because of her low income. In the past year she visited the emergency department (ED) seven times and was admitted three times, twice for heart failure after she ran out of a diuretic and once after a fall. She sees a primary care physician, a cardiologist and an endocrinologist at three different practices, none of which talk to each other. Her son lives two hours away and calls daily. She says she wants to stay in her own home and dreads a nursing home.

Her care is organized around providers and payers rather than around her. Each specialist sees one condition; Medicare pays for her hospital and physician care, Medicaid for her home help, and no one is responsible for the whole. This paper describes a client-focused alternative, the Program of All-Inclusive Care for the Elderly (PACE), explains how it would change her care, compares it with her current situation and places it within broader trends.

What Makes a Model Client-Focused

Client-focused care organizes services around the needs and goals of the person rather than around departments, disciplines or payment categories. Its features include a team that knows the whole person, services brought to or near the client, a single plan of care that all providers follow, clear responsibility for coordination and financing that rewards keeping people well rather than delivering more services. Mrs. Whitfield's current care has none of these features.

The PACE Model

PACE is a federally recognized model for people 55 and older who meet their state's criteria for nursing home level of care but can live safely in the community with support. Most participants, like Mrs. Whitfield, are eligible for both Medicare and Medicaid. PACE receives a fixed monthly payment per participant from Medicare and Medicaid and in return takes responsibility for all of the participant's care, including primary care, specialist care, hospital care, medications, home care, therapy, adult day services and transportation.

Care is delivered by an interdisciplinary team that typically includes a physician, nurses, a social worker, physical and occupational therapists, a dietitian, a recreation therapist, home care coordinators, personal care aides and drivers. The team meets regularly, and participants attend a PACE center, often several days a week, where they receive medical care, therapy, meals and social activity. Because PACE is paid a fixed amount, it has a financial reason to prevent hospital and nursing home stays.

How PACE Would Change Mrs. Whitfield's Care

Under PACE, one team would know her heart failure, diabetes, arthritis and cognition together. The PACE clinic would manage her medications and deliver refills, removing the gap that caused two admissions. A nurse at the center would weigh her and check for fluid build-up on the days she attends, catching heart failure early. Physical therapy would address her knee pain and fall risk, and a home assessment could lead to grab bars and a bathroom chair. The van would bring her to the center three days a week, where she would eat hot meals and see other people, which may help her cognition and mood. When she needs a specialist, the PACE team would arrange and share the visit, rather than leaving her to coordinate it herself. Her son would have one number to call.

The team would also plan ahead for her mild cognitive impairment. The social worker would help her name a health care agent while she can still make that choice clearly, and the team would record what matters most to her, staying at home and avoiding a nursing home, so that future decisions follow her wishes rather than a crisis. If her memory declines, the same team that already knows her would increase home visits and aide hours, and could arrange short respite stays, before a move out of her apartment is ever discussed. The contrast with her current care is sharp: today, a decline would most likely be discovered during another emergency visit.

Comparing the Models

The evidence favors PACE for people like Mrs. Whitfield, though it is not unlimited. Compared with similar frail older adults receiving other care, PACE participants spent an estimated 0.2 days per month in the hospital versus 0.8 days (Meret-Hanke, 2011). In a comparison with nursing home residents and people using home and community-based Medicaid waiver services, PACE participants were older and more cognitively impaired than waiver users, yet after accounting for risk, PACE had a significant survival advantage over the waiver, especially for higher-risk participants (Wieland et al., 2010). A 2024 review of integrated care programs for people eligible for both Medicare and Medicaid found that evidence generally showed reductions in long-term nursing home stays in PACE, while evidence on spending, hospitalizations and care coordination across integrated programs was mixed or limited (Roberts et al., 2024).

Limitations and Client Choice

PACE is not right for everyone. Participants must generally use PACE's own providers, so Mrs. Whitfield might need to leave her long-time cardiologist unless he contracts with the program. Attending a center requires some willingness to spend days in a group setting. PACE is also not available everywhere; many rural areas have no program. A human services professional would explain these trade-offs, arrange a visit to the local PACE center and respect her choice if she prefers to keep her current doctors and use other services instead.

Healthcare Trends Behind the Model

Three trends make models like PACE increasingly important. The first is the aging of the population, which is increasing the number of people living with several chronic conditions at once. The second is the movement toward integrated care for people eligible for both Medicare and Medicaid, who are among the costliest and most fragmented groups in the health system. The third is the shift from paying for services to paying for outcomes and populations, which rewards the kind of prevention and coordination PACE provides. Growth in home and community-based services, reflecting the preference of most older adults to age at home, runs through all three.

Technology is a fourth, smaller trend that strengthens the model rather than replacing it. Scales and blood pressure cuffs that report readings to the team, video visits on days she does not attend the center and electronic records shared across the team all make it easier for one team to watch a frail client closely. For Mrs. Whitfield, a scale that sends her weight to the PACE nurse each morning would extend the center's early warning for heart failure to the days she stays home. Trends like these do not make care client-focused by themselves; they help only when someone is responsible for acting on what they show.

Conclusion

Mrs. Whitfield's repeated trips to the emergency department are a symptom of care that nobody owns. A client-focused model such as PACE would give her one team, one plan and a reason for that team to keep her well at home. It is not the only answer, and the choice is hers, but it matches her needs better than the care she has now.

References

Meret-Hanke, L. A. (2011). Effects of the Program of All-Inclusive Care for the Elderly on hospital use. The Gerontologist, 51(6), 774-785. https://doi.org/10.1093/geront/gnr040

Roberts, E. T., Duggan, C., Stein, R., Jonnadula, S., Johnston, K. J., & Figueroa, J. F. (2024). Quality, spending, utilization, and outcomes among dual-eligible Medicare-Medicaid beneficiaries in integrated care programs. JAMA Health Forum, 5(7), e242187. https://doi.org/10.1001/jamahealthforum.2024.2187

Wieland, D., Boland, R., Baskins, J., & Kinosian, B. (2010). Five-year survival in a Program of All-Inclusive Care for Elderly compared with alternative institutional and home- and community-based care. The Journals of Gerontology: Series A, 65A(7), 721-726. https://doi.org/10.1093/gerona/glq040