Introduction to PACE
The Program of All-Inclusive Care for the Elderly, widely known as PACE, represents a significant advancement in healthcare for seniors. This government-funded model is specifically designed for individuals 55 years and older who, due to chronic conditions, require a level of care typically provided in nursing homes. Originating in 1971 in San Francisco, PACE has become a leading example of community-based integrated care in the United States. Its unique approach, utilizing a capitated payment system, allows for a comprehensive suite of services aimed at enabling older adults to live safely and independently within their own communities for as long as possible. PACE’s effectiveness is evident in reduced hospital stays and a markedly improved quality of life for seniors managing long-term health challenges. For those eligible, PACE can offer up to four additional years of independent living, all while maintaining a high standard of life within a familiar community setting.
Understanding the Core Issues and Benefits of PACE
PACE addresses the critical needs of seniors with chronic care requirements and their families. The central goal of PACE is to empower these seniors to maintain their independence in their homes and communities for as long as realistically possible. This innovative and effective care model is increasingly recognized as the gold standard for community-based integrated care, successfully fostering independence for individuals with significant healthcare needs. The Centers for Medicare & Medicaid Services (CMS) highlights the PACE model as a blueprint for the future of senior care in the United States, primarily because of its integrated approach to medical, behavioral, and social care for older adults dealing with chronic illnesses.
PACE operates on the fundamental principle that seniors with chronic health issues thrive best when they remain in their community environment whenever feasible. The program is tailored for individuals aged 55 and over who are state-certified as needing nursing home-level care, are capable of living safely in a community setting at enrollment, and reside within a PACE service area. Interestingly, the average PACE participant often presents with health profiles comparable to those in nursing homes, typically managing around eight medical conditions and experiencing limitations in three activities of daily living (ADLs). Notably, nearly half of PACE participants have a diagnosis of dementia. Despite these significant 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.
Enrolling in PACE grants participants access to a wide array of services, including:
- Adult Daycare: Offering nursing care, physical and occupational therapies, meals, nutritional counseling, recreational activities, social work services, and personal care.
- Comprehensive Medical Care: Provided by PACE physicians who are deeply familiar with each participant’s medical history, specific needs, and personal preferences.
- Home Health and Personal Care Services: Ensuring support within the participant’s home environment.
- Complete Prescription Drug Coverage: Managing all necessary medications.
- Social Services Support: Addressing the social and emotional well-being of participants.
- Specialized Medical Care: Access to audiology, dentistry, optometry, podiatry, and speech therapy.
- Respite Care: Providing temporary relief for family caregivers.
- Hospital and Nursing Home Care: Available when medically necessary.
The genesis of PACE in the 1970s in San Francisco’s Chinatown-North Beach area was a direct response to the lack of long-term care services for elderly individuals from immigrant families. Dr. William Gee led a committee that established the non-profit Chinatown-North Beach Health Care Planning and Development Corporation. They engaged Marie-Louise Ansak, a pioneer in senior care, who, through her research, determined that traditional nursing home models were financially unsustainable and culturally inappropriate for the community. Ansak collaborated with the University of California, San Francisco, to train healthcare professionals and drew inspiration from British day hospitals to create a system integrating housing, medical, and social services. This innovative model was eventually named On Lok Senior Health Services, with “On Lok” meaning “peaceful, happy abode” in Cantonese.
After two years of development, On Lok Senior Health Services opened its doors. As it began offering adult day health services, in-home care, meals, and housing assistance, Medicaid reimbursements started to support its operations. Approximately seven years after its inception, On Lok Health Services evolved to deliver a full spectrum of care for older adults with chronic conditions. In 1979, a 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 capitated payment system, providing a fixed monthly payment per enrollee. Federal legislation in 1986 expanded this financing model, allowing replication of this unique service across the US, officially becoming known as PACE. By 1990, PACE programs began to receive Medicare and Medicaid waivers to operate, and its capitated payment structure proved to be more cost-effective than traditional long-term care programs.
The National PACE Association (NPA), formed in 1994, plays a crucial role in supporting PACE programs. The NPA advocates for PACE programs, coordinating preventive, primary, acute, and long-term care services for enrollees. It collaborates with Congress, senior administration officials, and policymakers to foster a regulatory environment conducive to the growth and sustainability of PACE programs, ensuring high-quality, individualized care. The NPA also partners with other organizations to strengthen PACE’s capacity to deliver appropriate care and support families and caregivers of older adults in the United States.
The Balanced Budget Act of 1997 marked permanent recognition of PACE as a provider type under CMS (Medicare and Medicaid). In 2006, Congress initiated grants for rural PACE expansion following the publication of the Final Regulation. The PACE Innovation Act, passed by Congress in 2015 and signed into law by President Barack Obama, and the PACE Final Rule in 2019, further solidified the program’s framework.
PACE continues to expand across the United States. Building on the NPA PACE 2.0 initiative, the Alliance for PACE Innovation and Quality (APIQ) supports organizations in developing and maintaining PACE programs through grants from foundations like The John A. Hartford Foundation, West Health, and The Harry and Jeanette Weinberg Foundation. From its humble beginnings with On Lok Senior Health Services, PACE has grown to include 151 organizations operating in 32 states, serving over 68,000 participants.
Despite its growth, PACE is not yet available nationwide, with a concentration along the East Coast. Given the increasing senior population, with over 10,000 people turning 65 each day, further expansion of PACE is essential to meet the growing demand for elderly care. Affordability can also be a barrier to accessing PACE, depending on Medicare and Medicaid eligibility. Medicare eligibility generally starts at age 65 or for those with disabilities, while Medicaid requires demonstrating low income and resources. Individuals with Medicare but not Medicaid may face monthly premiums and medication costs. Those ineligible for both must cover long-term care costs and premiums for Medicare Part D drugs. Furthermore, the COVID-19 pandemic exposed challenges within long-term care models, including PACE, particularly concerning infection control and staffing shortages.
Clinical Significance of PACE
PACE’s increasing popularity in the United States is driven by mounting evidence that seniors with chronic illnesses experience better outcomes within community-based care settings. It is designed for individuals 55 and older who require nursing home-level care as certified by their state, are capable of living safely in the community upon enrollment, and reside within a PACE service area. The health profile of a typical PACE participant often mirrors that of a nursing home resident, characterized by approximately eight medical conditions, limitations in three ADLs, and a 50% chance of dementia. However, despite these complex needs, over 90% of PACE participants maintain community living and a good quality of life for up to four years.
PACE stands as the gold standard for integrated community-based care for chronically ill older adults in the US. Its significance as a healthcare model will only amplify as the senior population grows. Considering PACE is crucial for adults over 55 with chronic conditions who are eligible for nursing home care. The model is not only cost-effective but also associated with reduced hospitalization rates, shorter hospital stays, decreased caregiver burden, and enhanced quality of life. Legislative recognition in 1997 cemented PACE as a permanent provider type under CMS (Medicare and Medicaid). For patients qualifying for both Medicare and Medicaid, PACE offers comprehensive, affordable care, resulting in substantial savings for CMS.
Interventions by Nursing, Allied Health, and Interprofessional Teams
PACE is a government-funded initiative in the United States that delivers a complete spectrum of health services to chronically ill older adults who are at risk of institutionalization. It allows them to remain safely in their communities through an interprofessional team approach that coordinates participant care. These professionals possess specialized expertise in geriatric care and collaborate closely with participants and their families to develop personalized, effective care plans. This collaborative model within PACE is linked to increased primary care engagement, improved survival rates, better functional status, and enhanced quality of life, evidenced by greater social interaction and lower depression rates.
The interprofessional team approach is pivotal in PACE’s success in improving patient outcomes. Studies consistently show that PACE delivers accessible, high-quality, and cost-effective community-based care management for older adults who would otherwise require nursing home placement. In terms of healthcare resource utilization, PACE participants exhibit lower hospitalization rates, reduced readmissions, and fewer avoidable hospitalizations, along with shorter hospital stays. PACE enrollees not only experience fewer hospitalizations but also demonstrate improvements in mental and physical health, enabling them to live an average of four additional years in their communities with a higher quality of life, while their caregivers experience reduced stress.
Moreover, during the COVID-19 pandemic, which disproportionately impacted older adults in long-term care, PACE demonstrated its resilience. The interprofessional PACE care team effectively managed COVID-19 responses, safeguarding enrollees’ physical and mental well-being and addressing caregiver needs. The PACE model is also conducive to educating and training various healthcare professionals, including nurses, therapists, physician assistants, and medical residents. Furthermore, it supports quality improvement and research initiatives led by interprofessional teams to tackle common aging-related issues like falls and poor oral hygiene.
Economically, PACE’s capitated payment system is more efficient than traditional care models for equivalent patients, leading to significant Medicaid savings.
Monitoring by Nursing, Allied Health, and Interprofessional Teams
PACE services, authorized by the interprofessional team under the guidance of the participant’s primary care provider, encompass CMS (Medicare and Medicaid) services. This includes care from nurses, pharmacists, therapists, nutritionists, behavioral health specialists, and medical specialists like dentists, podiatrists, and optometrists. The team can also provide additional medically necessary services beyond those typically covered by Medicare and Medicaid. Frequent communication among the interprofessional team, participants, and their caregivers ensures coordinated care across various settings—homes, communities, PACE centers, hospitals, and nursing homes. Many PACE participants receive the majority of their care directly from the PACE interprofessional team and staff within the PACE center.
The PACE model emphasizes constant collaboration among participants, families, caregivers, primary care physicians, PACE staff, and other providers in all care decisions. This integrated approach gives the interprofessional PACE team significant control over patient outcomes and total care costs, most importantly, enabling participants to live safely in their communities for an average of four more years. PACE guarantees that care decisions are made jointly between the participant and the interprofessional team. Participants also retain the right to appeal if they disagree with their care plan.
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