The Program of All-Inclusive Care for the Elderly (PACE) represents a significant advancement in healthcare for older adults. Specifically designed for individuals 55 years and older who require a level of care typically provided in nursing homes due to chronic health conditions, PACE operates as a government-funded healthcare model. Since its inception in San Francisco in 1971, PACE has become recognized as a leading approach in the United States for delivering community-based, integrated care to the elderly. By utilizing a capitated payment system, PACE ensures a comprehensive suite of healthcare services are available, enabling older adults to live safely and independently within their own communities for as long as possible. This model not only contributes to reduced hospital stays but also greatly improves the overall quality of life for seniors managing long-term health needs. Through participation in PACE, eligible individuals can experience up to four additional years of independent, high-quality living in their community.
Key Considerations of the Program of All-Inclusive Care for the Elderly
The Program of All-Inclusive Care for the Elderly (PACE) is a unique healthcare model funded by the government, targeting individuals aged 55 and over with chronic illnesses. Eligibility for PACE requires state certification that the individual needs nursing home-level care. PACE distinguishes itself by employing a capitated payment system. This system allows enrolled participants access to a wide spectrum of care and services, all aimed at supporting them to continue living safely within their communities for as long as they are able. The origins of PACE can be traced back to 1971 in San Francisco’s Chinatown-North Beach area. Recognizing an urgent need for long-term care solutions for elderly immigrants, the community took action. Dr. William Gee spearheaded a committee that brought in Marie-Louise Ansak, a renowned innovator in geriatric care, to explore potential solutions. This initiative led to the formation of On Lok Senior Health Services, a nonprofit organization dedicated to creating a community-based care system. This system, which became known as PACE, is now celebrated as a benchmark for integrated community care for older adults with chronic conditions across the United States. Compared to other care models for seniors with long-term health issues, PACE is linked to fewer hospitalizations and a better quality of life. For older adults who are frail and meet the criteria for nursing home-level care, PACE can offer up to four more years of independent living with a high standard of life within their familiar community setting.
Understanding the Scope of PACE Services
The Program of All-Inclusive Care for the Elderly (PACE) is a government-supported healthcare model in the United States specifically tailored for older adults living in the community who have long-term health needs. PACE delivers a comprehensive range of health services. These include primary care and specialist medical attention such as audiology, dentistry, optometry, and podiatry. Additionally, PACE offers nursing care, various therapies (occupational, physical, recreational, speech), pharmaceutical support, nutritional guidance, meals, behavioral health services, social services, adult day health centers, home care, respite care, health-related transportation, and disability services. Beyond this extensive list, the PACE model is flexible and can incorporate other medically necessary services to further enhance the health of its participants.[1]
PACE was developed with both seniors who have chronic care needs and their families in mind. The primary objective is to help these seniors maintain their independence and remain in their own homes and communities for as long as realistically possible. This innovative, accessible, and effective model of care has proven successful in fostering independence among individuals with significant healthcare requirements and is widely acknowledged as the gold standard for integrated community-based care.[1][2] The Centers for Medicare & Medicaid Services (CMS) regards the PACE provider-sponsored health plan model as a blueprint for the future of care for older adults in the U.S. This is largely due to its integrated approach to medical, behavioral, and social care for seniors with chronic illnesses.[3]
PACE operates on the principle that older adults with chronic health conditions are best served within their community environment whenever feasible. It is designed for individuals aged 55 or older who are certified by their state as requiring nursing home care, are capable of living safely in a community setting at the time of enrollment, and reside within a PACE service area.[4] The typical PACE participant shares similarities with a nursing home resident. On average, a PACE participant is an older adult managing around 8 medical conditions, experiencing limitations or dependencies in 3 activities of daily living (ADLs), and nearly half have been diagnosed with dementia.[5] Despite these significant care needs, over 90% of PACE participants are able to continue living in their communities with a good quality of life for up to four years.[6]
Enrollees in PACE gain access to a comprehensive suite of services, including:
- Adult daycare services offering nursing care, physical and occupational therapies, meals, nutritional counseling, recreational activities, social work, and personal care.
- Medical care from a PACE physician who is familiar with the participant’s medical history, needs, and preferences.
- Home health care and personal care assistance.
- All necessary prescription medications.
- Social services support.
- Access to medical specialists in fields like audiology, dentistry, optometry, podiatry, and speech therapy.
- Respite care services for caregivers.
- Hospital and nursing home care when necessary.
The Historical Development of PACE
The PACE model was conceived in the 1970s in the Chinatown-North Beach neighborhood of San Francisco. The aim was to address the unmet need for long-term services for seniors from immigrant families. A committee, led by Dr. William Gee, a public health dentist, established the non-profit Chinatown-North Beach Health Care Planning and Development Corporation and enlisted Marie-Louise Ansak, a visionary and pioneer in senior care.[1] Ansak’s research revealed that the conventional nursing home model was not only financially unsustainable but also culturally unsuitable for the community’s needs. Instead, she collaborated with the University of California, San Francisco, to train healthcare professionals. Drawing inspiration from the British day hospital model, she designed a healthcare system that integrated housing, medical, and social services. This original model was eventually named On Lok Senior Health Services, with “On Lok” meaning “peaceful, happy abode” in Cantonese.
It took two years for On Lok Senior Health Services to commence operations. Initially offering adult day health services, in-home care, meals, and housing assistance, On Lok Senior Health Services began receiving Medicaid reimbursements. Approximately seven years after its inception, On Lok Health Services evolved to provide the full spectrum of care and services required by older adults with chronic care needs. In 1979, the organization secured a grant from the Department of Health and Human Services to develop a consolidated care model. By 1983, On Lok Senior Health Services was authorized to pilot a novel payment system. This system paid the program a fixed monthly sum for each enrolled participant, known as a capitated payment structure. Federal legislation in 1986 broadened the financing system, allowing other organizations across the United States to replicate this unique healthcare service model, which became formally known as PACE. By 1990, PACE was granted Medicare and Medicaid waivers to operate.[1] The capitated payment structure of PACE demonstrated cost-effectiveness, falling well below the expenditures for comparable patients in traditional long-term care programs.[2][7]
The National PACE Association (NPA) was established in 1994. The NPA is dedicated to promoting the efforts of PACE programs, assisting in the coordination and delivery of all necessary preventive, primary, acute, and long-term care services for PACE enrollees.[1] The NPA collaborates with Congress, senior administration officials, and policymakers to foster and regulate an environment conducive to the growth and success of PACE programs, ensuring they continue to offer high-quality, personalized, and innovative care. Additionally, the NPA partners with other organizations to advocate for strengthening the capacity of the PACE healthcare system to deliver appropriate care and to support the contributions of families, friends, and caregivers who assist older adults in the United States.
The Balanced Budget Act of 1997 marked a significant milestone, permanently recognizing the PACE model as a distinct provider type under CMS (Medicare and Medicaid).[1] The publication of the Final Regulation in 2006 led to Congress awarding grants for the rural expansion of PACE. Further legislative support came with the PACE Innovation Act, passed by Congress in 2015 and signed into law by then-President Barack Obama. The PACE Final Rule was officially published in 2019.
The PACE model continues to expand its reach across the United States. Building upon resources developed under the NPA PACE 2.0 initiative, the Alliance for PACE Innovation and Quality (APIQ) offers support and consultation to organizations interested in establishing and maintaining PACE programs. This is made possible through grants from The John A. Hartford Foundation, West Health, and The Harry and Jeanette Weinberg Foundation.[1] Thanks to these organizational efforts and funding opportunities, PACE has grown significantly from its initial On Lok Senior Health Services program to encompass 151 PACE organizations operating in 32 states across the United States, serving over 68,000 participants.
However, despite the ongoing growth of the PACE healthcare model in the United States, it is not yet universally accessible and is predominantly concentrated along the East Coast. With the older adult population increasing by over 10,000 people daily [8], further expansion of the PACE model is essential to meet the growing needs of this demographic.[3] Affordability can also be a barrier to accessing PACE care, depending on an individual’s eligibility for Medicare and Medicaid.[4] Medicare eligibility generally requires individuals to be 65 or older or have a disability. Medicaid eligibility is based on demonstrating low income and limited resources. Individuals with Medicare but not Medicaid are responsible for monthly premium fees and medication costs. Those ineligible for both Medicare and Medicaid are responsible for long-term care payments and premiums for Medicare Part D drugs. Lastly, like all forms of long-term care for older adults, the COVID-19 pandemic exposed vulnerabilities in the PACE model, notably highlighting challenges in infection control and staffing shortages.[9]
Clinical Importance of PACE
PACE stands as a government-funded healthcare model designed for older adults with chronic illnesses and long-term healthcare needs. Its increasing prominence in the United States is supported by growing evidence demonstrating that seniors with chronic conditions thrive better within their community settings.[3][6][10][11][12][13] Eligibility criteria include being aged 55 or older, state-certified as needing nursing home-level care, capable of living safely in the community at enrollment, and residing in a PACE service area.[4] The average PACE participant’s profile is comparable to that of a nursing home resident, often managing about 8 medical conditions, experiencing limitations or dependencies in 3 ADLs, and with approximately a 50% chance of having dementia.[5] Despite these significant care needs, over 90% of PACE participants maintain their community living with a good quality of life for up to 4 years.[6]
PACE is recognized as the gold standard for integrated community-based care for older adults with chronic illnesses in the United States. Its significance as a healthcare model will only increase as the older population continues to expand, with over 10,000 individuals joining this demographic every day.[8] It is crucial to consider PACE as a viable healthcare option for adults over 55 with chronic medical conditions who qualify for nursing home care. This model is not only cost-effective but also associated with lower hospitalization rates, shorter hospital stays, reduced burden on caregivers, and an improved quality of life for participants.[8][3][6][10][11][12][14][15] Legislative actions in 1997 formally recognized the PACE model as a permanent provider type under CMS (Medicare and Medicaid). For patients who qualify for both Medicare and Medicaid, this comprehensive care level is affordable and results in considerable cost savings for CMS.[4][2][7]
Interventions by Nursing, Allied Health, and Interprofessional Teams
PACE is a model for government-funded programs in the United States that deliver a complete spectrum of health services to older adults with chronic illnesses who would otherwise require institutionalization. This model enables them to live safely within their communities. An interprofessional team is central to coordinating participant care, ensuring an innovative and holistic level of care. These professionals possess expert-level experience in working with older individuals and collaborate closely with participants and their families to develop personalized, effective care plans. This close collaboration between participants and the interprofessional PACE team has been linked to increased primary care engagement, improved survival rates, better functional status, and a higher quality of life, evidenced by increased social interaction and decreased rates of depression.[10][11][13]
The interprofessional team approach has consistently demonstrated success in enhancing patient outcomes. Research indicates that PACE offers accessible, high-quality, and cost-effective community-based care management for older adults who might otherwise be placed in nursing homes.[3] Regarding healthcare resource utilization, studies have shown that PACE participants experience lower hospitalization rates, reduced readmissions, and fewer potentially avoidable hospitalizations compared to similar populations, with shorter hospital stays ([8][10][11][12][14][15]. Patients enrolled in PACE not only had fewer hospitalizations but also showed improvements in mental and physical health. This allowed participants to live an average of 4 additional years in their community and maintain a significantly higher quality of life, while their caregivers experienced reduced stress levels.[3][6][10][11][12][13]
Moreover, during the COVID-19 pandemic, which disproportionately affected older adults and those in long-term senior care, PACE proved effective in its COVID-19 response. The interprofessional PACE care team successfully upheld safety standards, promoted the physical and mental well-being of enrollees, and addressed the needs of caregivers.[9] The PACE model is also conducive to the education and training of various healthcare professionals, including nurses, therapists, physician assistants, medical residents, and fellows [16]. Furthermore, it supports quality improvement and research initiatives, with interprofessional teams conducting and implementing studies to tackle common aging issues like falls and poor oral hygiene.[17][18]
From a financial perspective, PACE’s capitated payment system has shown to be more economical than alternative care models for equivalent patients, leading to significant savings for Medicaid.[2][7]
Monitoring by Nursing, Allied Health, and Interprofessional Teams
PACE delivers CMS (Medicare and Medicaid) services as authorized by an interprofessional team, which is guided by the participant’s primary care provider and includes nurses, pharmacists, therapists, nutritionists, behavioral health specialists, and medical specialists like dentists, podiatrists, and optometrists. This team is also authorized to provide additional medically necessary care and services beyond those typically covered by Medicare and Medicaid. Frequent communication among the interprofessional team, participants, and their caregivers is essential for coordinating care across various settings, including participants’ homes, the community, PACE centers, hospitals, and nursing homes. A significant portion of PACE enrollees receive the majority of their care from the interprofessional team and staff employed by the PACE organization, primarily at the PACE center.[11][15][13]
The PACE model fosters continuous collaboration among participants, their families and caregivers, the primary care physician, all PACE staff, and other involved care providers in all decision-making processes. It provides the interprofessional PACE team with comprehensive oversight of patient outcomes and total care costs. Most importantly, it empowers participants to live safely in their communities for an average of 4 additional years.[3] PACE ensures enrollees that all care decisions are made collaboratively between the participant and the interprofessional team. However, participants retain the right to appeal if they disagree with their care plan proposed by the interprofessional team.
References
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Disclosure: Carla Williams declares no relevant financial relationships with ineligible companies.
Disclosure: Soumya Chandrasekaran declares no relevant financial relationships with ineligible companies.
