The PACE Model: A Comprehensive Approach to Elderly Care

“The PACE model is the only prescribed clinical, social, and behavioral care model that exists. It is the only approach in health care that I know reliably extends life.”

— Andy Slavitt, Former CMS Administrator (Home Health Care News, July 2023)

What is PACE?

The Program of All-Inclusive Care for the Elderly (PACE) is a fully integrated health plan and provider that delivers comprehensive medical and supportive services to frail adults aged 55 and older who meet the state-defined nursing home level of care. Through PACE, these individuals receive essential medical and long-term supportive services, allowing them to remain in their communities rather than transitioning to a nursing home.

PACE operates under a fully capitated model, with Medicare and Medicaid coverage, making it responsible for all healthcare costs across all care settings. Eighty percent of PACE participants are dually eligible for both Medicare and Medicaid.

Currently, PACE programs operate in 33 states and Washington, D.C. Since 2019, the number of PACE organizations has grown by 28%, and total PACE enrollment has increased by 50%—significantly outpacing general Medicaid growth, which has ranged between 9% and 19%.

Key Benefits of PACE:

Enhanced Quality of Life: Participants report a higher quality of life compared to other care models for older adults with long-term health needs.
Reduced Hospitalizations: PACE is associated with lower hospitalization rates and shorter lengths of stay.
Support for Family Caregivers:
- PACE significantly reduces caregiver burden and provides essential support.
- According to the National PACE Association, 95% of family caregivers would recommend PACE to others who could benefit.
Prolonged Independence: Eligible participants—who would otherwise require nursing home care—can gain up to four additional years of independence in their communities.

The PACE Model of Care

A core pillar of PACE is care coordination by an interdisciplinary team (IDT), ensuring high-quality, cost-effective care tailored to each participant’s needs. Each PACE program includes a brick-and-mortar PACE Center, serving as a hub for medical, therapeutic, and social services.

PACE participants are not only elderly and frail, but also have multiple chronic medical conditions and complex care needs that qualify them for long-term nursing home care.

PACE Participant Demographics (National PACE Association, January 2024):

67% are women
96% live in the community
Average age: 76 years
46% have dementia
Participants typically manage six or more chronic medical conditions

The Role of Healthcare Technology in PACE

Advancements in healthcare technology present significant opportunities to improve patient enrollment, facilitate education for patients and caregivers, and enhance care coordination. Like other CMS programs PACE programs have reporting requirements which requires technology that is easy to use and designed for this kind of program. Below are areas outside of mandatory reporting where technology can support PACE programs:

1. Enhancing and Streamlining Patient Enrollment

Given that enrollment is critical in capitated programs, effective marketing plays a key role:

Reputation management through online reviews
Multi-channel marketing leveraging technology to reach potential participants and caregivers

2. Providing Ongoing Education to Patients and Caregivers

Educational initiatives can help patients manage their medical conditions and reduce reliance on excessive medications (polypharmacy):

Lifestyle modification support through omnichannel education, ensuring accessible information on wellness and chronic disease management
Campaigns promoting preventive care, ensuring healthcare maintenance and routine screenings are not overlooked

3. Facilitating Cost-Effective Care Coordination

Managing a frail and medically complex population requires efficient resource allocation and individualized care strategies:

Technology enables better resource allocation, allowing some patients to receive remote monitoring and regular communication, reducing unnecessary in-person visits while maintaining quality care
Customized patient interaction, ensuring that the frequency and type of communication align with both patient preferences and medical necessity, thereby improving outcomes without overburdening the healthcare workforce

Conclusion

PACE is a proven, cost-effective model that enhances the quality of life for older adults, prolongs independence, and reduces caregiver burden. By integrating technology-driven solutions, PACE programs can further streamline enrollment, optimize care coordination, and ensure that patients and caregivers receive the education and support they need.