# Program of All-Inclusive Care for the Elderly

Program of All-inclusive Care for the Elderly (PACE) are programs within the United States that provide comprehensive health services for individuals age 55 and over who are sufficiently frail to be categorized as "nursing home eligible" by their state's Medicaid program. The ultimate goal of PACE programs is to keep eligible older adults out of nursing homes and within their communities for as long as possible. Services include primary and specialty medical care, nursing, nutrition, social services, therapies (occupational, physical, speech, recreation, etc.), pharmaceuticals, day health center services, home care, health-related transportation, minor modification to the home to accommodate disabilities, and anything else the program determines is medically necessary to maximize a member's health. If you or a loved one are eligible for nursing home level care but prefer to continue living at home, a PACE program can provide expansive health care and social opportunities during the day while you retain the comfort and familiarity of your home outside of day hours.

## History

PACE was developed by On Lok Senior Health Services, a not-for-profit community-based organization launched in the early 1970s in the Chinatown-North Beach area of San Francisco, California.
1971–1978
On Lok Senior Health Services was created in 1971 to address the long-term care needs of older immigrants in San Francisco's Chinatown-North Beach neighborhood. After its founding, between 1973 and 1975, On Lok expanded to include day centers, in-home care, home-delivered meals, and housing assistance. In 1974, On Lok started being reimbursed by Medicaid for its provision of adult day health services. Later, in 1978, these health services were broadened to include comprehensive medical care for older adults certified to be nursing home-eligible.
1979
The Department of Health and Human Services provided a four-year grant to On Lok to develop a model of care delivery for individuals with long-term care needs.
1986-1987
10 other organizations implemented the care delivery model developed by On Lok, with approval from the federal level. In 1987, the 11 existing sites received funding from the Robert Wood Johnson Foundation, John A. Hartford Foundation, and Retirement Research Foundation.
1990
The care delivery model developed by On Lok became known as "Program of All-Inclusive Care for the Elderly" or PACE. The first replication sites received Medicare and Medicaid waivers.
1994
The National PACE Association (NPA) was formed.
1997
The Balanced Budget Act of 1997 (P.L. 105–33, Section 4801-4804) established PACE as a permanent part of the Medicare program and an option under state Medicaid programs.
2005-2006
The Deficit Reduction Act (DRA) of 2005 authorized a Rural PACE initiative and in 2006, the Centers for Medicare and Medicaid Services (CMS) announced 15 rural PACE grantees.
2015
President Obama signed the PACE Innovation Act into law.
2019
As of 2019, there were 130 PACE organizations in 31 states, serving over 50,000 individuals.

## Eligibility

To be eligible for PACE, individuals must be at least 55 years old; be certified to need nursing home-level care by the state; reside near a PACE program; and be able to safely reside in the community with the help of PACE.

## Program description

PACE delivers patient-centered, comprehensive care to frail and elderly adults through a collaborative team of providers, including but not limited to physicians, nurses, registered dietitian, physical therapists, and social workers. The goal of the team is to help PACE members to reside in their community independently as long as possible, by providing them with tailored services or resources that support their physical wellbeing, mental health, Activities of Daily Living (ADL), and Instrumental Activities of Daily Living (IADL). PACE programs emphasize on preventional and health promotional day-care that can impact members' end-of-life care and prevent more expensive care from skilled nursing facilities.
Under funding from the CMS, PACE provides all services covered by the Medicare and Medicaid. PACE may also cover services outside the scope of Medicare and Medicaid funding, as long as the providers deem the service necessary. Most PACE participants have co-morbidities, including cardiovascular diseases, diabetes, and hypertension. PACE provides services including primary care, home care, labs, medications, recreational therapy, social services, counseling, transportation to care facilities, and more. By providing all-inclusive care for the participants, PACE maintains the health of members and prevent exacerbation of current medical conditions. Patients are less likely to request extensive acute care, nursing facility care, or in-patient services. Under this method, PACE serves as a cost-saving elderly care program that emphasizes on preventative, up-stream care. Notably, PACE programs saved California State $22.6 million in health care cost for elderly.
PACE programs organize their services in "PACE Centers". Currently, there are 272 PACE Centers in 30 states, serving around 55,000 participants. PACE Centers serve as comprehensive care centers that include services that would otherwise require accessing primary care offices, social services, rehabilitation centers, recreational facilities, and more. Services such as routine care, exercise programs, dietary monitoring, strength training, and mental health services are provided out of these centers. The goal is to reduce burnout from caregivers and provide support for the members. The centers are regularly accessible to members; they can participate daily, weekly, or monthly depending on their needs. Care decisions are made at these centers between the members, their care team, and any caregivers.

## Financing

PACE receives monthly funding from the CMS under risk-adjusted per-member payments, or capitation. Medicaid covers the monthly premium of long-term care, and Medicare covers the rest. For PACE participants who are qualified for Medicare but not Medicaid, they are responsible for monthly premium equal to the Medicaid capitation fee and the premium for medications under Medicare Part D. Participants who are not eligible for Medicare or Medicaid can still be eligible for PACE, but will be responsible for the cost of the program.

## Outcomes

Several studies point to the numerous benefits that PACE programs have had on their patient populations, including allowing them to live safely within their communities.
The more positive research on effectiveness centers on outcomes of interest tied to PACE programs. These include greater adult day health care use along with decreased numbers of hospitalizations and nursing home admissions. In fact, patients were less likely to be institutionalized when compared to those who waived 1915(c) home- and community-based services.
Similarly, it has been noted that patients remain in contact with primary care longer; have greater survival rates, better health, better functional status, and better quality of life as reflected by increased social interaction; and experience less depression and fewer concerns after enrollment.
There are, however, some drawbacks that patients have come to perceive with certain aspects of the PACE experience. Some patients have reported that they are not receiving enough information about their conditions and that their input into their own care is not being taken into consideration by providers. In addition, there is a prevalent concern amongst enrollees centered on losing their primary care physician with whom they have established a relationship and trust with.