Ramon Fuentes Jr. had finally started to settle into a Denver assisted living facility, participating in activities and making a lady friend, and his daughter hoped the 75-year-old would be able to spend the rest of his days there.
Then came the news that the program they were counting on to cover his bills after he spent most of his savings on care might not be there when he needed it.
The federal Program of All-Inclusive Care for the Elderly, or PACE, is for people 55 and older who would qualify for the level of care provided in a nursing home, but who also could safely stay at home if they had enough support. Medicaid pays a set rate for the services they receive, which another agency delivers. Some clients live in assisted living facilities, with PACE coordinating their medical care and providing support for those facilities may not offer.
PACE providers have contracts to serve certain geographic areas, but InnovAge — the company responsible for much of metro Denver — has been barred from taking on new customers since December. Inspections had found InnovAge’s centers were understaffedand that clients hadn’t consistently received basic services like insulin injections, wound care and assistance getting in and out of bed.
InnovAge is the only PACE provider for Adams, Arapahoe, Broomfield, Denver, Jefferson, Larimer and Pueblo counties, and for part of Weld County. About 3,500 people were enrolled in the company’s six Colorado centers when enrollment was frozen.
While people currently enrolled in PACE continue to receive services through the program, others who would like to join don’t have that option unless they move to a county with an active provider. They also can rely on traditional Medicaid but might have to uproot their loved one if the facility where they live doesn’t accept it.
Cameron Crawford, owner of the Next Steps Senior Placement agency, which serves Front Range communities from Boulder to Colorado Springs, said the enrollment freeze has created a “rapidly growing” problem, and families don’t have many options other than moving their loved ones to nursing homes or to other counties.
“The InnovAge freeze is creating a bottleneck and Denver does not have enough Medicaid assisted living and memory care beds to compensate for the frozen InnovAge beds,” she said. “This is especially problematic for anyone who needs secure memory care.”
Fuentes’ daughter Rebecca Edmonds, of Castle Rock, said a friend who works in the elder care industry warned her that her father wouldn’t be able to enroll in PACE for the foreseeable future. He would qualify for traditional Medicaid, but the facility where he was living hasn’t gotten certified by the state to take residents covered by it.
Fuentes has post-traumatic stress disorder from his service in the Vietnam War as well cognitive impairment, and the combination makes it difficult for him to adjust to new surroundings, Edmonds said. Moving him from Denver to Lark Springs, an assisted living facility in Colorado Springs, wasn’t ideal, but she was worried that if she waited any longer, there wouldn’t be a bed available in a suitable home.
“If you’re going to be selective about where you send your loved one, you may only have one or two options,” she said.
It’s not clear how many families are facing a similar choice. Bonnie Silva, director of community living at the Colorado Department of Health Care Policy and Financing, urged families who are sure about their options to contact their single-entry-point agency that coordinates care for older people. In the Denver area, that’s Rocky Mountain Human Services.
“If they have not connected with their local single entry point, we need them to do that,” she said.
Georgia Edison, chief program officer for Rocky Mountain Human Services, said they always start by counseling new clients about their options. Services provided in people’s homes may be an alternative for those who wanted to enroll in PACE, she said.
“The intent of all the long-term service programs with which we work is to help people to maintain as much independence as possible while remaining in their homes and communities,” she said.
InnovAge was required to identify all potential clients they were working with who were still in the process of spending down their assets to qualify for Medicaid and PACE, so they could do individual outreach, Silva said. Just allowing InnovAge to start taking new clients again isn’t an option, she said, because they weren’t giving existing clients what they needed.
“We want to make sure that they have quality care,” Silva said. “We want to see sustained progress.”
Sarah Rasmussen, a spokeswoman for InnovAge, said they’re referring families who come looking for help to other options, including the single-entry-point agencies. The state and federal Centers for Medicare and Medicaid Services will determine when InnovAge can take new clients again, so it’s not possible to give a timeline at this point, she said.
“We continue to work closely with CMS and the state of Colorado to address their findings,” she said in a statement. “InnovAge looks forward to opening our doors once again to PACE-eligible participants in our Colorado communities and we remain focused on providing quality care to each senior currently enrolled in PACE.”
“Too big to fail”
Judy Gaylor, of Omaha, Nebraska, said her sister-in-law Sharron Gaylor had to move to three different Denver-area facilities in the past year, trying to find one that offered the memory care she needed and that would take her coverage.
Gaylor said an InnovAge representative encouraged her and husband Harry to sign Sharron up for the program, so they moved her to a facility that contracted with the company. She didn’t get in before the PACE enrollment freeze, though, and had to go on traditional Medicaid, requiring another move.
Sharron seems happy at the Arvada facility where she landed, but the process was stressful, Gaylor said. The placement companies they worked with didn’t always have accurate information, and some facilities didn’t make clear whether they took PACE clients or traditional Medicaid, she said.
“It’s just very confusing,” she said.
Silva estimated about 200 assisted living facilities in the Denver area participate in traditional Medicaid, though she didn’t know how many were accepting new clients. The state is trying to make it easier for more facilities to enroll so that their residents can stay in place as their private pay funds run out, she said. Those efforts include waiving the application fee and assigning a staff person to shepherd them through.
“We will provide sort of a white-glove experience,” she said.
The state was already transitioning to requiring assisted living facilities that contract with PACE to be certified by Medicaid, a process that began about a year ago, Silva said. If facilities opt not to do that, they could only take residents who can pay for their own care.
Dave Lewis, who owns 14 small assisted living facilities, estimated his facilities have five residents who expected PACE to take over covering their care by now, and five more will be in that situation in the near future. He said only one of his facilities accepts Medicaid, and he doesn’t want to get the others certified, following disagreements over whether they could have a camera in a common area and whether cognitively impaired residents should be issued room keys.
Lewis said he had thought of InnovAge as “too big to fail,” and thought the state would complement a management company to improve it without suspending new enrollments. Tru PACE, which operates in Boulder and Weld counties, is expanding into the northern part of the metro area, but the need to hire staff and set up centers means it can’t just jump into the market, he said.
Lewis said he told Tru PACE, “you need to get to Lakewood, because I have people in Lakewood who are running out of money. We’ve been working with them. Families have been chipping in. But I definitely foresee some move-outs coming.”
Tru PACE representatives didn’t return messages from The Denver Post seeking comment about any expansion plans.
“This stressful, painful situation”
Nicole Zamparelli-Schiavone, president of the board of the Colorado Assisted Living Association, said PACE agencies are easier to work with than the state, especially since they handle residents’ medical care and don’t require lengthy inspections. For some facilities, it’s not feasible to comply with Medicaid’s building requirements for fire safety, and the documentation and billing process is “cumbersome,” she said.
The process of getting certified “can be quite costly, and then it is a lot of work to stay up with the Medicaid regulations,” she said.
Colorado doesn’t have enough spots available in nursing homes for all the people who need them, Zamparelli-Schiavone said. In one case, a person who needed more care than the assisted living facility where they were staying could provide waited 115 days for a bed, she said. While many nursing homes technically have beds available, they don’t have enough staff to care for more residents.
The shortage of beds has left some families wondering what they’ll do if their loved ones’ money runs out before PACE resumes enrollment in Denver.
Ellory Hartnett, of Englewood, said she expected the PACE program to take over covering her father’s spot at a Denver assisted living facility after he spends down most of his assets, though he wasn’t yet enrolled. If PACE isn’t taking new members in Denver by the time his savings run out, she’ll have to find a facility that accepts traditional Medicaid. She cared for him at home before, but that’s not an option at this point, she said.
Her father, Lonnie Hartnett, has dementia, and changes in his routine are hard for him, Hartnett said. For now, she’s trying to stretch his money to keep him in a home where he’s happy for as long as possible. But it’s not a permanent solution.
“I had his finances planned around that, so I’m worried,” she said. “It’s just wrong to put families who are already going through this stressful, painful situation through more.”