Stay-at-Home Elders

· Two thousand people living at home in Oregon and Washington will each receive a "Health Buddy" computer that can transmit blood pressure and other readings to clinicians who can then ask the patient, via questions that pop up on the monitor, what might be amiss. (The patient replies by pushing one of four buttons on the screen.) The medical staff can then decide whether the patient needs to be seen.

· In New York, similar devices and additional on-site services will be provided to up to 7,000 residents of "naturally occurring retirement communities," or NORCs -- housing complexes where most residents are older than 60.

· In Texas, California and Florida, 15,000 Medicare patients will be able to receive round-the-clock home visits from physicians. The goal is to improve care while reducing expensive emergency room visits and hospital admissions.

The Department of Veterans Affairs also operates a home care program that serves 11,000 people with multiple health problems. In a statement at a Capitol Hill meeting of the White House Conference on Aging last month, Thomas Edes credited the program with "a 62 percent reduction in hospital days and a substantial reduction in emergency room visits and nursing home days."

Edes, a physician who oversees the program, said that although it costs nearly $10,000 per person per year, "this comprehensive home care to this very sick population was associated with a net 24 percent reduction in total cost of care."

A team of nurse practitioners, social workers, rehabilitation therapists and dietitians visit homebound patients and their caregivers to deliver medical care along with information about meals, exercise, medications and community resources. A major goal is to help keep patients at home as long as possible; the program also includes palliative care for those nearing death.

"I believe this model of care should be available for all Americans as they live with serious illness in old age," Edes said.

One-Stop Shopping

One similar program is available -- if not for all Americans, at least for those who are sick enough by Medicaid's standards to qualify for nursing home care, who live in certain states and who have a nearby medical institution with deep financial pockets and the willingness to try something new. It's called PACE, the Program of All-inclusive Care for the Elderly.

Eleven thousand people in 18 states are enrolled in PACE programs, which combine Medicare and Medicaid funding -- about $4,800 per person per year, on average. The sponsoring organization, which receives those funds, is responsible for delivering a comprehensive package of medical care and social services -- ordinarily at a day care center, sometimes at the person's home, and even at a hospital or nursing home if the participant needs to be admitted. According to the National PACE Association, the average age of people joining the program is 80 and half of new enrollees have at least some dementia.

Virginia and the District have no such programs. Maryland's sole PACE location is in Baltimore, where dozens of elderly people are brought daily to a center where they receive medical care, occupational therapy, social services, meals and other assistance from Hopkins ElderPlus, sponsored by the Johns Hopkins Medical Institutions.

Karen Armacost, the program's director, said it's not difficult to fill the 150 slots in the program, even though two or three participants die in a typical month.

Satisfaction is high among participants and their caregivers, who find it "wonderful to be able to have this one place to go to for answers and guidance. . . . A lot of people refer to it as one-stop shopping. . . . The thing that they most appreciate is the comprehensiveness and the coordination of the care," Armacost said.

"Once a person enrolls, we provide all the care that they need for the rest of their life," said Robert Greenwood, a vice president of the PACE association. "If they need to go to the hospital, we pay for the hospital care; if they need to go to a nursing home, we pay for the nursing home care. So the reason this model works is because the program . . . will invest money in keeping people out of hospitals and out of nursing homes, because that's where we lose money. It's such a nice model because it really aligns the financial incentives with the clinical incentives and with what people want."

Why aren't there more PACE programs? Among the factors, according to Greenwood, is that some states prefer to spend their Medicaid dollars on other projects. In addition, "there are major start-up costs," Armacost said, "and a lot of health systems and organizations just don't have those kinds of start-up funds." Just as the Washington Hospital Center helped get the house call program underway, Hopkins provided the Baltimore PACE program with seed money. Armacost said the cost of creating a program and subsidizing it while the first participants are enrolled can be as high as $2.5 million.

As for what that investment produces, the value of the PACE program can be measured in different ways.

"When we poll our participants and caregivers, 100 percent say they would recommend the program to a family member or friend," said Armacost. On the other hand, Greenwood said, "the cost-benefit analysis is a little bit more difficult": a thorough study of the financial impact of PACE won't be done for a few years. ·