Variations in service use in the Program of All-Inclusive Care for the Elderly (PACE): Is more better?

Background. To date, there has been little empirical evidence about the relationship between service use and risk-adjusted functional outcomes among the frail, chronically ill elderly population. The Program of All-Inclusive Care for the Elderly (PACE) offers a unique model within which to investigate this relationship. We examine variation in the risk-adjusted utilization of acute, rehabilitative, and supportive services in PACE, and assess whether use of these services is associated with risk-adjusted functional outcomes. Methods. The analytical sample included 42,252 records for 9853 individuals in 29 programs, over 3 years. Outcome was measured as change in functional status. Service use was assessed for hospital and nursing home admissions, day center attendance, therapy encounters, and personal home care. Mixed regression, generalized estimating equation (GEE) log-linear Poisson models and bootstrap procedures were used. Results. We examined the marginal effect of the five services on functional status over time, having controlled for each program's risk-adjusted use of services and functional status of their enrollees. We observed a statistically significant association between hospital admissions and functional status. Sites using more hospital care had worse functional outcomes. We found no other significant relationship between functional change and service use. However, correlations between program-level measures showed that sites providing more day center care and more therapy had significantly fewer hospital admissions. Conclusions. Findings suggest that programs with high hospital use may do well to re-examine and adjust the intensity of day center care. Greater focus on service provision in this setting may enhance care coordination and lead to reductions in hospitalizations, better outcomes, and cost savings.