A Focus on Program of All-Inclusive Care for the Elderly (PACE): Revolutionizing Senior Healthcare

Definition and Introduction to PACE

The Program of All-Inclusive Care for the Elderly (PACE) represents a significant advancement in healthcare, specifically designed for individuals aged 55 and over who require a level of care typically provided in nursing homes. This innovative, government-funded healthcare model originated in San Francisco in 1971 and has since become a nationally recognized standard for community-based, integrated care for older adults. PACE operates on a capitated payment system, enabling it to deliver a comprehensive spectrum of healthcare services. This holistic approach empowers elderly individuals to maintain their independence and continue living safely within their own communities for as long as possible. The benefits of PACE are well-documented, including reduced hospital stays and a marked improvement in the quality of life for seniors managing long-term health needs. Through participation in a PACE program, eligible older adults can gain up to four additional years of independent, high-quality living within their familiar community environment.

The Program of All-Inclusive Care for the Elderly (PACE) is formally defined as a government-funded healthcare model dedicated to serving individuals 55 years of age and older with chronic illnesses who, as certified by their respective state, necessitate nursing home-level care. PACE’s financial structure is based on a capitated payment system, which allows enrollees access to a comprehensive and continuous range of care and services. The overarching aim is to support these individuals in living safely and independently in their communities for as long as realistically feasible. The PACE model’s inception can be traced back to 1971 in San Francisco, born from the urgent need for long-term care services identified within the Chinatown-North Beach community, particularly for the elderly within immigrant families. Dr. William Gee spearheaded a committee that recruited Marie-Louise Ansak, a visionary and pioneer in geriatric care, to explore potential solutions. This initiative led to the formation of On Lok Senior Health Services, a non-profit organization created to establish a community-centric care system. This system evolved into what is now known as PACE, widely acclaimed as the gold standard for integrated, community-based healthcare for chronically ill older adults across the United States. Compared to traditional care models for seniors with long-term health issues, PACE is notably associated with fewer hospitalizations and a higher quality of life. Importantly, PACE can offer frail older adults who qualify for nursing home-level care as much as four extra years of independent living, all while maintaining a high standard of life within their own communities.

Key Concerns Addressed by PACE

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 with long-term health needs who reside in their communities. PACE provides a wide array of comprehensive health services, including primary and specialist medical care (covering audiology, dentistry, optometry, podiatry, and more), nursing care, various therapies (occupational, physical, recreational, speech, etc.), pharmaceuticals, nutritional guidance, meals, behavioral health services, social work support, adult day health centers, home care, respite care, health-related transportation, and disability services. Beyond this extensive list, the PACE model is designed to be flexible, allowing for the inclusion of other medically necessary services that can further benefit participants’ health and well-being.[1]

PACE was specifically designed to meet the complex needs of seniors with chronic conditions and their families. The fundamental objective is to enable these seniors to maintain their independence and continue living within their familiar home communities for as long as possible. This innovative and accessible care model is highly effective in fostering independence for individuals with substantial healthcare requirements and is broadly recognized as the benchmark for community-based integrated care.[1, 2] The Centers for Medicare & Medicaid Services (CMS) highlights the PACE provider-sponsored health plan model as a blueprint for the future of senior care in the United States. This is largely due to PACE’s unique ability to integrate medical, behavioral, and social care for older adults managing chronic illnesses.[3]

PACE operates on the core principle that seniors with chronic health conditions are best served within their community setting whenever possible. Eligibility for PACE is extended to individuals aged 55 or older who are certified by their state as needing nursing home-level care, are deemed capable of living safely in a community environment at the time of enrollment, and reside within a PACE service area.[4] The average PACE participant’s health profile is often comparable to that of a nursing home resident. Typically, a PACE participant is an older adult managing approximately eight medical conditions and experiencing limitations or dependencies in three activities of daily living (ADLs). Significantly, nearly half of PACE participants have a diagnosis of dementia.[5] Despite these considerable care needs, over 90% of PACE participants are able to continue living in their communities, enjoying a good quality of life for up to four years.[6]

Once enrolled in PACE, participants gain access to a comprehensive suite of services, including:

• Adult Daycare: Featuring nursing care, physical and occupational therapies, meals, nutritional counseling, recreational activities, social work services, and personal care assistance.
• Personalized Medical Care: Provided by a PACE physician who is deeply familiar with the participant’s medical history, individual needs, and preferences.
• Home Healthcare and Personal Care Support: Delivered in the comfort of the participant’s residence.
• Comprehensive Prescription Drug Coverage: Ensuring access to all necessary medications.
• Social Services: Addressing the broader social and emotional needs of participants.
• Specialized Medical Services: Including audiology, dentistry, optometry, podiatry, and speech therapy.
• Respite Care: Offering temporary relief for family caregivers.
• Hospital and Nursing Home Care: Available when medically necessary, ensuring a continuum of care.

The PACE model was originally conceived in the 1970s in the Chinatown-North Beach area of San Francisco to address the pressing need for long-term care services for elderly immigrants. A committee, led by public health dentist Dr. William Gee, established the non-profit Chinatown-North Beach Health Care Planning and Development Corporation. This organization then enlisted the expertise of Marie-Louise Ansak, a visionary and pioneer in senior care.[1] Ansak’s research concluded that the traditional nursing home model was not only financially unsustainable but also culturally unsuitable for the specific needs of this community. Instead, she collaborated with the University of California, San Francisco, to train healthcare professionals. Drawing inspiration from the British day hospital model, she formulated a healthcare system that integrated housing, medical, and social services. This original model was later renamed On Lok Senior Health Services, with “On Lok” meaning “peaceful, happy abode” in Cantonese.

It took two years of dedicated effort to open the doors of On Lok Senior Health Services. As the organization expanded its services to include adult day health programs, in-home care, meal provisions, and housing support, On Lok Senior Health Services began receiving Medicaid reimbursements. Approximately seven years after its inception, On Lok Health Services had evolved to provide the complete spectrum of care and services required by older adults with chronic care needs. In 1979, a significant grant from the Department of Health and Human Services enabled the development of a consolidated care model. By 1983, On Lok Senior Health Services was authorized to pilot a novel payment system: a fixed monthly payment for each enrolled participant, known as a capitated payment structure. Federal legislation in 1986 expanded this financing system, allowing other organizations across the United States to replicate this unique healthcare service model, which became officially known as PACE. By 1990, PACE secured Medicare and Medicaid waivers to operate broadly.[1] Notably, PACE’s capitated payment structure demonstrated cost-effectiveness, remaining significantly below the expenditures for comparable patients in alternative long-term care programs.[2, 7]

The National PACE Association (NPA) was established in 1994 to further the mission of PACE programs. The NPA plays a crucial role in coordinating and supporting PACE programs to deliver comprehensive preventive, primary, acute, and long-term care services to their enrollees.[1] The NPA actively engages with Congress, senior administration officials, and policymakers to advocate for and regulate an environment conducive to the growth and sustainability of PACE programs, ensuring they continue to offer high-quality, individualized, and innovative care. The NPA also collaborates with other organizations to strengthen the PACE healthcare system’s capacity to provide appropriate care and to support the essential roles of families, friends, and caregivers in assisting older adults across the United States.

The PACE model achieved permanent recognition as a distinct provider type under CMS (Medicare and Medicaid) through the Balanced Budget Act of 1997.[1] The publication of the Final Regulation in 2006 led to Congressional grants aimed at expanding PACE into rural areas. Further legislative support came with the PACE Innovation Act, passed by Congress in 2015 and signed into law by President Barack Obama. The PACE Final Rule was officially published in 2019, solidifying its regulatory framework.

The PACE model continues to expand its reach across the United States. Building on resources developed under the NPA PACE 2.0 initiative, the Alliance for PACE Innovation and Quality (APIQ) now offers support and consultation to organizations interested in establishing and maintaining PACE programs. This is made possible through grants from prominent foundations such as The John A. Hartford Foundation, West Health, and The Harry and Jeanette Weinberg Foundation.[1] Fueled by these organizational efforts and funding opportunities, PACE has grown remarkably from its initial roots at On Lok Senior Health Services to encompass 151 PACE organizations operating in 32 states across the United States, serving over 68,000 participants.

Despite its growth, the PACE healthcare model is not yet universally available nationwide, with a concentration along the East Coast. Given that over 10,000 individuals join the older population daily [8], further expansion of the PACE model is crucial to effectively serve the increasing number of older adults.[3] Affordability can also be a barrier to accessing PACE, dependent on an individual’s eligibility for Medicare and Medicaid.[4] Medicare eligibility generally begins at age 65 or for those with disabilities, while Medicaid requires proof of low income and limited resources. Individuals with Medicare but not Medicaid typically face monthly premium fees and medication costs. Those ineligible for both Medicare and Medicaid are responsible for long-term care expenses and premiums for Medicare Part D drugs. Lastly, like all forms of long-term care for older adults, the COVID-19 pandemic exposed vulnerabilities within the PACE model, particularly concerning infection control and staffing shortages.[9]

Clinical Significance of PACE

PACE is a vital government-funded healthcare model designed for older adults with chronic illnesses and long-term healthcare needs. Its increasing popularity in the United States is driven by mounting evidence that seniors with chronic conditions thrive better within their community environments.[3, 6, 10, 11, 12, 13] Eligibility criteria include being aged 55 or older, state certification as requiring nursing home-level care, the ability to live safely in the community at enrollment, and residence within a PACE service area.[4] The typical PACE participant shares similar health characteristics with nursing home residents, often managing an average of eight medical conditions, experiencing limitations in three activities of daily living (ADLs), and having approximately a 50% chance of dementia diagnosis.[5] Despite these significant care needs, over 90% of PACE participants maintain their community living status with a good quality of life for up to four years.[6]

PACE stands as the gold standard for community-based integrated care for older adults with chronic illnesses in the United States. Its significance as a healthcare model will only amplify as the older population continues to grow, with over 10,000 individuals entering older adulthood each day.[8] Considering PACE as a primary healthcare option is essential for adults over 55 with chronic medical conditions who are eligible for nursing home care. This model is not only cost-effective but also linked to lower hospitalization rates, shorter hospital stays, reduced caregiver burden, and an enhanced quality of life for participants.[8, 3, 6, 10, 11, 12, 14, 15] The PACE model’s permanent recognition as a provider type under CMS (Medicare and Medicaid) since 1997 underscores its importance. For patients who qualify for both Medicare and Medicaid, PACE offers comprehensive, affordable care, resulting in substantial cost savings for CMS.[4, 2, 7]

Interventions by Nursing, Allied Health, and Interprofessional Teams in PACE

PACE operates as a network of government-funded programs across the United States, delivering a complete spectrum of health services to older adults with chronic illnesses who are at risk of institutionalization. PACE enables these individuals to live safely within their communities through innovative and holistic care coordinated by an interprofessional team. These professionals possess specialized expertise in geriatric care and collaborate closely with participants and their families to develop personalized and effective care plans. This strong collaborative approach between PACE participants and the interprofessional team has been shown to increase primary care engagement, improve survival rates, enhance functional status, and elevate overall quality of life, evidenced by increased social interaction and reduced rates of depression.[10, 11, 13]

The interprofessional team approach is a cornerstone of PACE’s success in improving patient outcomes. Studies consistently demonstrate that PACE provides accessible, high-quality, and cost-effective community-based care management for older adults who would otherwise require nursing home placement.[3] In terms of healthcare resource utilization, research indicates that PACE participants experience lower hospitalization rates, reduced readmission rates, and fewer potentially avoidable hospitalizations compared to similar populations, alongside shorter hospital stays.[8, 10, 11, 12, 14, 15] Furthermore, PACE enrollees not only experience fewer hospitalizations but also show improvements in both mental and physical health. This allows participants to live an average of four additional years in their communities with a significantly higher quality of life, while their caregivers report reduced levels of stress.[3, 6, 10, 11, 12, 13]

During the COVID-19 pandemic, which disproportionately affected older adults and those in long-term care, PACE demonstrated its resilience and effectiveness in managing the crisis. The interprofessional PACE care team successfully implemented COVID-19 response strategies that prioritized safety, promoted the physical and mental well-being of enrollees, and addressed the needs of caregivers.[9] The PACE model also serves as an excellent platform for educating and training various healthcare professionals, including nurses, therapists, physician assistants, medical residents, and fellows [16]. Moreover, PACE facilitates quality improvement initiatives and research, with interprofessional teams conducting and implementing studies to address common aging-related issues such as falls and poor oral hygiene.[17, 18]

Economically, PACE’s capitated payment system has proven to be significantly more cost-effective than alternative care models for equivalent patients, generating substantial savings for Medicaid.[2, 7]

Monitoring by Nursing, Allied Health, and Interprofessional Teams within PACE

PACE delivers services covered by CMS (Medicare and Medicaid) as authorized by the participant’s interprofessional team, which is typically led 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 empowered to provide additional medically necessary care and services beyond those traditionally covered by Medicare and Medicaid. The interprofessional team maintains frequent communication with participants and their caregivers to effectively coordinate care across various settings, including participants’ homes, community locations, PACE centers, hospitals, and nursing homes. Many PACE enrollees receive the majority of their healthcare directly from the interprofessional team and staff employed by the PACE organization and based at the PACE center.[11, 15, 13]

The PACE model fosters continuous collaboration among participants, their families and caregivers, the primary care physician, the entire PACE staff, and other involved care providers in all aspects of decision-making. This collaborative approach gives the interprofessional PACE team comprehensive oversight of patient outcomes and total cost of care. Crucially, it enables participants to live safely within their communities for an average of four additional years.[3] PACE ensures that all care decisions are made transparently and in partnership between the participant and the interprofessional team. However, participants retain the right to appeal if they disagree with the care plan proposed by the interprofessional team, ensuring their voice and preferences are always considered.

References

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