Michelle Jackson, MS, OTD, OTR/L

Welcome to the MaxiOT podcast where we invite occupational therapy practitioners, consumers, and friends of OT to talk about evidence-based practice. Today we'll be talking to Michelle Jackson about the program of all inclusive care for the elderly or pace. Many of us have identified the barriers to healthcare and other social opportunities our clients face. I'm so excited to learn more about this program addressing many of these challenges today. Let's meet Michelle. Today on the MaxiOT podcast we'll be talking with occupational therapist Michelle Jackson about the program of all inclusive care for the elderly or pace. This program provides comprehensive medical and social services to frail elderly people living in the community. Michelle just recently told me about this program and I can't believe I've never heard of it. I can't wait to learn more from her today. Michelle thanks so much for joining us here on the MaxiOT podcast. Hi Sarah, it's such a pleasure to be here. I actually love talking about my job and about pace programs so I'm really excited to be here today. Oh great. I'm glad you're excited and I know that feeling. This is why I have a podcast because I can talk about OT stuff all day. You and I just met actually virtually as well on a panel for OT students and I loved hearing about your work and to be honest I think I would love to have your job. Can you tell us a little bit more about your background and how you came to work with this population? Actually, for the first 17 years of my career I worked in pediatrics. So it was kind of a long road getting here. I guess after 17 years I felt like I needed to make a little bit of a change and I took a job working in an assisted living facility. From there I moved to home health and I kind of fell in love with community-based care and I feel like everything that I did in that home health job really set me up perfectly to be able to move into this job that I have now at a pace facility. So yeah, that's how I got here. Wow. Yeah. And that's what we tell our students all the time, right? You can always change populations, change areas of practice. So great to hear your example of that today. And we're going to kind of get more into what the pace program looks like. But I think first it'd be helpful to know how do people qualify for this or how do they pay for it? Okay. So to qualify for a pace program, the participants must be financially eligible. So this program is for low income, older adults. They must be eligible for both Medicare and Medicaid. So and they also must be certified by the state to require a nursing home level of care, but also be able to continue living in the community given appropriate supports. In addition, pace programs have catchment areas. So participants must reside within that program's eligible zip codes. Wow. Well, that's a lot of factors that folks have to think about. And I think that's really interesting to wrap your head around. I'll qualify for SNF level of care, but also demonstrate ability to live in the community. That's a, I'm sure kind of a tricky thing to figure out sometimes. It is tricky, but you know, it's the, it's the perfect challenge for an OT, right? Yeah. Sure. So maybe can you tell us a little bit more about what the pace program looks like? What services are included? Okay, so pace programs are capitated Medicare and Medicaid programs that provide primary care, occupational and physical therapy, nursing, medical daycare, nutrition, social work, recreation, home health, AIDS, and consultation for specialty services. In addition, pace programs provide transportation to medical appointments. And these services are really geared towards older adults with chronic health conditions, with again, that goal of keeping them at home as long as possible. Wow. I mean, what an amazing package. You know, again and again on this podcast and in the profession, we've talked about the barriers to healthcare, the barriers to participation. And it's programs like this that really help to bridge those gaps. Exactly. I mean, and these are people with really complex medical and often social pictures. So it's a lot. But we do provide these sort of this holistic approach. Absolutely. And so, you know, Michelle, the service is provided in the pace program. They are available elsewhere in the community. So what are some of the benefits of providing them all inclusively in this one program? So I think the primary benefit of a pace program would be the continuity of care. So we act as both the insurance and the medical provider. And so we're able to provide wraparound services for participants. A second, and I think very important benefit would be the case management. Individuals with chronic health conditions require significant medical management. They often require durable medical equipment that's likely not covered by other insurance programs and social supports to promote access to care, food sometimes, and even appropriate housing. Wow. Again. What a resource. I'm so glad I met you and I'm so glad that I'm learning about this. And I know that I'll be able to recommend these programs to, you know, clients as they work on aging in place. And that's correct me if I'm wrong, but the OT provided, is it provided in the adult day program? So the services that OT's providing a pace program can vary from program to program based on how they developed their particular pace program. For example, in an urban pace facility, you know, that may allow for clinicians to make more home visits, where is an rural program that catchment area may be so large that regular home visits are really not feasible for clinicians to manage. The program that I work in is an urban program. And so we make a lot of home visits. Most pace programs have a therapy space in their facility that allows for participants to receive intervention on days they attend daycare. However, because pace programs are designed to support community dwelling older adults, home visits are often necessary to ensure the appropriate supports are in place. In my current position, OT's manage home safety assessments make recommendations for DME and home modifications. We oversee the delivery and installation of equipment and work at some cases even with contractors to ensure that the home modifications are completed. We also are evaluating participants every six months to monitor their function, keeping in mind that all of the participants have chronic diseases which progress. You know, whether we like it or not. So we have an expectation that we need to monitor their function regularly. So we do provide skilled intervention as needed and that is something that would happen, you know, more than likely on the days that they do come to the center. You know, for example, we may see a participant twice a week following a fall with a fracture or after a TIA or a stroke. And that's something that would probably be provided on days that they actually come to the center. But some of the home safety stuff we do out in the community. That makes total sense. And again, I think as OT's, we so recognize that context is so important and that we need to be in clients homes and often there's so many barriers, particularly just around the systems that we have in place here in the state. So that's so cool. And so does everyone that comes into a pace program, do they all get evaluated by OT? So every individual upon evaluation has both an OT and a PT evaluation. And then those evaluations recur every six months. Wow. Because again, we know that folks slip through the cracks, right? Either families or physicians don't recognize the value of OT, don't recognize that it could be covered even if there hasn't been some sort of extenuating event. What a perfect program, what a perfect setup to just have OT there. And like you were saying, then if there's a change, you can come in and do more, but you'll know that you'll be reassessing in six months and checking in. Right. Exactly. And we do, if there is a very obvious change of status, that's another reason that the entire team would do another evaluation as well. That makes sense, yeah, for sure. And so like you said, you work with a whole team. How do you collaborate with some of the other professionals you're working with? So in my program we started each day with an interdisciplinary morning meeting to review any significant changes that participants may have had in the previous 24 hours. That could be a hospitalization, a fall, it could be moved to or from an assisted living facility, even just a discharge from the hospital, a change in behavior, even something as simple as an inability to contact or participate, right? We know that that could potentially be something happening there if we weren't able to get in contact with someone, concerns from a caregiver. So all of these things would come up in our morning meeting, which usually lasts anywhere between, I would say, 25 and 45 minutes depending on what has come up overnight. And then of course, like we said, every six months, each participant has got undergone an assessment and their care plan is updated by every member on the team. This is also reviewed in a meeting where the participant and/or the caregiver has the opportunity to ask questions, make comments about what's being presented by each discipline. So the participant is an active member of the team as well. That's so great. And you know, I'm just curious, this is one of those more just kind of day-to-day questions, but the OT's have a lot, you know, what does your typical day look like or what is your productivity requirement? It's really a luxury to get to have a 25 to 45 minute meeting to go over your cases. So that just makes me wonder kind of how your day is scheduled. So the day, like I said, does start with morning meeting. For us, that's around 815 in the morning. And again, that's, it's over when it's over sometimes it's quick, sometimes it's not. But the time it's over, our participants are starting to roll in, down in our day health center, which is the daycare area. They're getting a small breakfast. We can go down and start to interact. And then at that point, when they've had their breakfast, they can come on up into our therapy gym. And we can start doing any intervention, you know, that could be done reasonably in the center. And so typically between the hours of, I would say, maybe 9.30 and 2. We're seeing participants in our therapy gym or down in the day health center. Then they start going home around 2 o'clock. And at that point, we would typically start doing home visits for the rest of the day. Maybe one or two home visits, maybe following up, if there are no home visits to be done, maybe following up on the ordering of equipment, making equipment deliveries. Again, there's a lot of case management. So doing a lot of emails, back and forth with other providers and other disciplines. If we have participants that are in, say, a skilled nursing facility, they maybe had a fall, spent a short period of time in the hospital, then transferred to a skilled nursing facility. I'm reviewing all of their therapy documentation to see where are they. Are they back at their baseline? I know what their baseline is because I work with them. I know what their health looks like. I know what their social supports are. I know what we can provide and what they'll need to be able to go home. So I'm often interacting and maybe even visiting some of those skilled nursing facilities to say, okay, well, I know if this person weren't in our program, you would say there's no way they can go home yet. But I know what we can provide and I know what their baseline was. And maybe they can go home a little bit early or, you know, maybe even just the opposite. I'd like for them to stay a little bit longer. Wow. What a support. I, you know, for, I think that's often a barrier with discharge planning when folks are in in patient rehab or skilled nursing or even acute care kind of really being able to gauge from seeing somebody in this clinical setting to how they're going to function at home. And for an OT to have such an understanding of this person's context, right? And I'm just also thinking about what a, you know, I think a lot of OT's, the grind of, you know, 90% productivity back to back to back. Maybe if you're in need of a change, something like this might be kind of that change of pace that some OT's are looking for. Some hate case management and would have no interest in this role. But it sounds like a really interesting job with a lot of diverse activities that you're doing every day. Yeah. I came from home health, which of course had productivity standards and this job does not. I mean, there's a lot of case management involved, but I really, I don't mind that at all. And I like the fact that I have so many different responsibilities throughout the day. For me, that kind of keeps me motivated, it keeps me going. I love patient care, but I think I've hit a point for me in my career where, you know, eight hours of patient care is a little bit much for me. And I really like kind of reviewing some documentation and ordering equipment and acting as more of a consultant at this point. So it's a really good fit for me. And I think for a lot of clinicians, it could be a really great fit. Yeah. I really think that that diversity of activities in your days just sounds. I guess that's why I have enjoyed the changes that I've made recently too. I'm reflecting on my own professional experiences too. And so, but I'm sure it's not all perfect, right? What are some of the challenges that you face when working in this program? Well, I think on any team, you know, there's going to be challenges around communication and role delineation. I think that's always going to be a problem on any kind of team that you're on. When it comes to working with participants, you know, the complexity and the progression of the chronic health conditions coupled with, you know, some of the demographics can be really challenging, you know, for example, health literacy and general literacy can be very challenging with this population. Again, like I mentioned, not only do you have to be of a low income, but you have to be at a level where you would likely require a nursing home level of care. So we're looking at, you know, a lot of factors here which make caring for these participants challenging. It's a lot to juggle, I guess you could say. That's probably the biggest, you know, there's always so many factors that we're looking at with each with each individual. Again, I think occupational therapists are really uniquely qualified to do this just because we have such a person-centered approach and we are already so prepared to look at the full picture. We're already viewing the individual in the context of their environment, of their physical environment, of their social environment. So I think that we have a really unique education and background and our values are perfectly geared towards this, but that doesn't make it any less challenging. It's still a lot. It's still a lot, but it's so important to have OT in that team to be thinking about, you know, like you said, their environmental context or social context, their cognitive abilities, their physical abilities. But also, I can see why it's so important to have those morning meetings. That it's important that OT has time for case management to make sure that you're juggling all of those factors. Right, right, exactly. Yeah, very cool. So then on the flip side, do you have a success story that you'd like to share with us? Well, I mean, I can't because of Hippi, I can't give you any specifics, but I can give you, you know, maybe some sort of a sort of like a made up case study, if you will. Let's just take a young man, maybe with a history, young, I'm meaning late 50s, with a history of substance use, which then potentially led to let's say a stroke, limited social supports in part because of the previous lifestyle, you know, limited access to care and resources. Right, so what we're able to put in place is durable medical equipment. Right, we all know that Medicare doesn't cover things like tub transfer benches. Right, all those little pieces of equipment that are really challenging for somebody on a low income to purchase. Right, so we can go ahead and we can put in some durable medical equipment, put a home health aid in place. So maybe a couple times a week, they have supervision for bathing. In some cases, we will even provide once or twice a month home cleaning. Those are things that are really challenging for somebody with mobility impairments. Maybe meals on wheels. Make sure that they're fed and they're fed healthy. Depending of course on the PACE program, I know my PACE program has a contract with addiction treatment services. So we're able to provide support and behavioral health supports for them. And now so we've got this person who, you know, this individual who has very complex history, but we're able to support them living in an apartment, right? Independently with some supports in place. So they're able to maintain a sense of autonomy and independence in the community. And, you know, at this point, OT can even start to work on things like leisure development, right? I feel like that's the ADL that, that you know, always gets pushed to the side, but we can really, you know, we put all these other things in place and we get to follow them. And now we can say, okay, so you're safe at home. We've given you your equipment. What do you want to do? So yeah, it's like I said, it's really just sort of a wrap around. I we've had clients that are maybe even six or seven years post stroke. And because they come regularly to the day health center and they'll come on up to therapy and they'll engage in the interventions presented and they're so making gains, you know, they're, you know, so. And with those supports in place with maybe the appropriate DME or adaptive equipment, updated orthotics, all those things that are so hard to manage, you know, when you think about the amount of follow up it takes if you have this many chronic conditions, right? You know, you have to make follow up appointments with all of your different specialists. You have to get your transportation to all of these different specialists. You have to consider how are you going to have access to food? How are you going to cook that food? And these are things that we are able to really look at the environment, where are they living, what are their abilities, cognitive, physical abilities, what are their social supports that they have in place and fill in those gaps for people so that they can continue to stay in the community and engage and participate, right? Isn't that what it's all about for OOTS? Right. We want them to participate. We want them to engage to do. Right. That's exactly what I was thinking about and I was thinking about managing chronic health conditions and when you were talking about like, well, maybe we could work on some leisure, right? How much more motivating, how much more likely is someone going to be moving, using their brains, you know, like that's such an important part that unfortunately doesn't get addressed because of insurance limitations and other factors. Yeah, for me, I think the fact that I'm able to make really appropriate equipment recommendations and as insurance provider, we make those purchases and that I'm able to address all aspects of the person's life, including leisure, is really probably what makes this job for me. It's like I know what they need and in most instances, I'm able to provide it. Maybe not perfectly, but you know, it's just a great situation to be able to go in and say, okay, we put everything in place now, you've got all the equipment you need. Let's play. Yes. And so Michelle, I don't mean to put you on the spot. So if you don't have an answer to this, that's fine because this wasn't in our list of questions, but I often hear it sort of quoted, right, that it's less expensive to provide care so people can stay in their homes than it is to provide skilled nursing in a skilled nursing facility. Do you know of any statistics like is paste programs demonstrating that? Yeah. I mean, the statistics indicate that paste programs are cost effective, right? So that, and that's why they continue to grow and they continue to open across the country. So paste programs, it's and don't quote me on this, but I believe they've only been in existence for about 25 years, maybe slightly longer, but they continue to grow. It's, it really becomes the state's decision how they want to invest their Medicaid dollars. They want to invest those Medicaid dollars in supporting paste programs, but it's definitely a cost effective way to manage health care. I mean, we really do keep people at home. And that doesn't mean just out of a skilled nursing facility that also means out of the hospital. You know, if somebody is having, they're, we're not over utilizing the emergency departments, which we know can be a problem in areas where there is low health literacy and where there is low income, right? So we're able to keep people out of those emergency rooms. Yeah, I think that that's a critical piece of this, right? Is that people are like exactly what you just said. We're not just keeping people out of nursing homes. We're having less hospital admissions, which everybody ever since the ACA passed, everybody's very invested in. And I just think it's so interesting that often those these things, these less expensive health care things, it's really important to the OT's in there. Like that's the only way we're going to keep people in their homes. And we really need to remember that and advocate for us to be in any of these home programs. Oh, I completely agree. I think community-based care is the perfect setting for OT and as health insurance changes and as we're seeing more and more community-based care, it's a real opportunity for OT's to really step into that and to really shine. It is. And so I guess I'm getting on my soapbox a little bit, but we need to not ask for a seat at the table for those conversations. We need to show up and use programs like this to provide that evidence that this is really important to OT's there. Absolutely. Well, Michelle, thank you so much for this conversation. And as you know at the Maxi OT podcast, we always want to make sure we provide an opportunity for our listeners to increase their maxi. So if occupational therapy practitioner wanted to learn more about paste programs, what resources would you recommend they check out? So I would say the best one is to probably go to the CMS website. They have a page devoted to paste programs. Paste programs also have a national organization, the National Paste Association or NPA and that's NPA online. I think it's.org. I'd have to look back when up. And then there are several larger paste programs out there where maybe there's a company, well be health is one that comes to mind that has several paste programs, Eden Bridge, Innovage, all run several paste programs. Great. Yeah, I think that our listeners would enjoy poking around those pages, seeing what these are about. And I have a feeling there's going to be some OT's applying for new jobs soon. So thank you so much for this conversation. This was great. Thanks for having me. I really enjoyed it. Thanks for joining us for this great conversation with Michelle Jackson about the program of all inclusive care for the elderly. Today we're highlighting an article presenting a case study of an older adult whose multiple medical conditions are not able to be managed effectively through traditional services in the American healthcare system. This article identifies four programs including the paste program that improve access to comprehensive care for older adults. The authors also reported on current evidence for these programs. The paste program was evaluated in several studies, each of which compared participants in the paste group with control participants who were receiving different packages of medical and supportive services in their local communities. One study found paste participants had significantly fewer hospital admissions and preventable ER visits and hospital admissions per month compared with a community-based analog of paste. It's exciting to see how interprofessional programs including occupational therapy can impact the lives of our clients. We'll have the links to this article and all of the resources Michelle discussed on our website. If you want more tools to employ evidence-based practice, check out our website. Our four professionals page has resources to support your use of evidence-based practice. The Maxi OT podcast was recorded in our home in the Avondale neighborhood of Chicago. This episode was produced by Brian Zira. Our intro music is courtesy of 13 Tacos Studio. Thanks for joining us. We'll see you next time. [Music] [BLANK_AUDIO]