SF-Based FQHC Adds Telehealth, Remote Patient Monitoring to PACE Services

One of the nation’s largest non-profit federally qualified health centers is integrating telehealth and remote patient monitoring services into its PACE program to improve care for thousands of underserved seniors in and around San Francisco.

North East Medical Services, which serves more than 65,000 people through 12 clinics in San Francisco, Daly City and San Jose, is partnering with LucidAct Health, a Silicon Valley-based virtual care company, to enhance its Program of All-inclusive Care for the Elderly (PACE) platform, launched earlier this year to serve residents of San Francisco’s Chinatown region.

The NEMS PACE program provides comprehensive medical and social services to low-income, eligible seniors of whom a majority are dually eligible for Medicare and Medi-Cal. Roughly 90 percent of those seniors identify as Asian, creating a need for a program that includes digital literacy, translation and an understanding of cultural issues.

The partnership will add RPM and telehealth services to the program, allowing the FQHC’s care providers to monitor patients at home and connect with them via virtual channels when needed.

“The care team at NEMS PACE is excited to pilot this innovative technology,” NEMS PACE Program Director Sharon Raver-Villanueva said in a press release. “Many of our PACE participants face obstacles using virtual care with the current tools available due to advanced and complicated technology that is difficult for seniors to navigate. Our population is further challenged with low-English proficiency.”

Jerry Jew, the program’s chief strategy officer, said the enhanced program will allow providers and patients to connect via easy-to-use mHealth devices with multi-language capability on a 4G or 5G LTE network. The service will integrate with NEMS’ electronic health record platform, and it’ll use AI tools to sift through the data, making sure the right information goes to the right care provider.

“We believe that a comprehensive care delivery system for our PACE participants is the key to better health equity while ensuring safety and comfort from their home,” he said.

Developed by the Centers for Medicare & Medicaid Services roughly 30 years ago as a capitated model of care for dual-eligible beneficiaries (90 percent are dual eligible), PACE provides all necessary medical care, therapies, long term care and services, meals, socialization, transportation, day center services and activities.

There are more than 135 PACE programs in more than 30 states, enrolling between 50 and 3,000 patients, for a total of more than 54,000 seniors served. The programs are typically based in a care center and feature an interdisciplinary care team (IDT) of primary care physicians, nurses, therapists, social workers, dieticians, home care professionals and others and offers a variety of services on-site and in the home.

Telehealth and RPM haven’t typically been a part of the PACE toolbox, though some programs had been experimenting with connected health as a means of expanding the program’s effectiveness. That changed with COVID-19, which prompted many programs to embrace virtual care, looking to continue their services while reducing in-person visits and potential exposure for a vulnerable population.

Many of those programs are now looking to make those services permanent. And a bill introduced to Congress this past March seeks to establish Medicare coverage for certain telehealth services beyond the pandemic.

“Telehealth is definitely not a replacement (for in-person care), but it gives us more tools, and we want to use these tools for what our participants desire,” says Matt Patterson, president of WelbeHealth, a Menlo Park-based PACE provider who’s been integrating telehealth into programs in Fresno, Long Beach, Pasadena and Stockton-Modesto. “As an organization, we only do well when our participants do well. And they’re doing well.”