1 

Program of All-Inclusive Care 

for the Elderly (PACE)

Program Description 

The Program of All-Inclusive Care for the Elderly (PACE) features a comprehensive and seamless service delivery 

system and integrated Medicare and Medicaid financing. Eligible individuals are age 55 years or older and meet the 

clinical criteria to be admitted to a nursing home but choose to remain in the community. An array of coordinated 

services is provided to support PACE participants to prevent the need for nursing home admission. An 

interdisciplinary team, consisting of professional and paraprofessional staff, assesses participants’ needs; develops 

care plans; and delivers or arranges for all services (including acute care and, when necessary, nursing facility 

services), either directly or through contracts. PACE programs provide social and medical services, primarily in an 

adult day health center setting referred to as the “PACE center,” and supplement this care with in-home and 

referral services in accordance with the participants’ needs. Each participant can receive all Medicare- and 

Medicaid-covered services, as well as other care determined necessary by the interdisciplinary team. 

Important note about implementation requirements:

For a health care organization to be approved as a PACE program, the State must elect PACE as a voluntary State 

option under its Medicaid plan. In addition, the prospective PACE organization and the State must work together 

in the development of the PACE provider application. On behalf of the prospective provider, the State submits 

the application to the Centers for Medicare and Medicaid Services with assurance of the State’s support of the 

application and its contents. Each approved PACE program receives a fixed amount of money per PACE 

participant regardless of the services the participant utilizes. 

Descriptive Information 

Areas of Interest 

 Health and wellness 

 Long-term services and supports 

 Mental health promotion 

Outcomes 

Review Date: October 2012 

 Care management 

 Health status, functioning, and mental health 

 Utilization of health services 

 Long-term survivability 

Review Date: June 2007 

 Utilization of medical services 

 Utilization of support services 

 Perceived health status, functional status, and overall quality of life 

 Mortality rate 

 Comorbidity diagnoses 

Ages 

 50–60 (Older adult) 

 61–74 (Older adult) 

 75–84 (Older adult) 
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 85+ (Older adult) 

Genders  Female 

 Male 

Races/Ethnicities 

 Asian 

 Black or African American 

 Hispanic or Latino 

 White 

 Race/ethnicity unspecified 

Settings 

 Home 

 Outpatient 

 Residential care facility 

 Other community settings 

Geographic Locations 

 Urban 

 Suburban 

 Rural and/or frontier 

Adverse Effects No adverse effects, concerns, or unintended consequences were identified by the 

developer. 

Implementation History 

The PACE model of care can be traced to the early 1970s, when the Chinatown 

community of San Francisco saw the pressing need for long-term-care services for 

immigrant elders and their families. The On Lok Senior Health Services nonprofit 

corporation was formed to create a community-based system of care based on the 

British day-hospital model, combining housing, medical, and social services. In 1997, 

Federal legislation authorized PACE as a permanent Medicare benefit and a Medicaid 

State plan optional service. As of August 2014, there were 104 PACE organizations 

providing care to more than 30,000 individuals in 31 States. 

Adaptations No population- or culture-specific adaptations were identified by the developer. 

Quality of Research 

Review Date: October 2012 

Documents Reviewed 

The documents below were reviewed for Quality of Research. The research point of contact can provide 

information regarding the studies reviewed and the availability of additional materials, including those from 

more recent studies that may have been conducted. 

Study 1 

Beauchamp, J., Cheh, V., Schmitz, R., Kemper, P., & Hall, J. (2008). The effect of the Program of All-Inclusive Care 

for the Elderly (PACE) on quality. Final report presented to Centers for Medicare & Medicaid Services. Princeton, 

NJ: Mathematica Policy Research. Retrieved from https://www.cms.gov/Research-Statistics-Data-andSystems/Statistics-Trends-and-Reports/Reports/downloads/Beauchamp_2008.pdf 
3 

Study 2 

Wieland, D., Boland, R., Baskins, J., & Kinosian, B. (2010). Five-year survival in a Program of All-Inclusive Care for 

Elderly compared with alternative institutional and home- and community-based care. Journals of Gerontology, 

Series A: Biological Sciences and Medical Sciences, 65(7), 721–726. PubMed abstract available at 

http://www.ncbi.nlm.nih.gov/pubmed/20354065

Study 3 

Meret-Hanke, L. A. (2011). Effects of the Program of All-Inclusive Care for the Elderly on hospital use. 

Gerontologist, 51(6), 774–785. PubMed abstract available at http://www.ncbi.nlm.nih.gov/pubmed/21737398

Supplementary Materials 

Carey, E. C., Covinsky, K. E., Lui, L.-Y., Eng, C., Sands, L. P., & Walter, L. C. (2008). Prediction of mortality in 

community-living frail elderly people with long-term care needs. Journal of the American Geriatrics Society, 

56(1), 68–75. PubMed abstract available at http://www.ncbi.nlm.nih.gov/pubmed/18031487

Considerations for Monitoring Quality Assurance Across PACE Centers 

National Pace Association. (n.d.). How NPA supports PACE programs. Alexandria, VA: Author. 

Outcomes 

Outcome 1: Care Management 

Description of Measures 

Care management was assessed through a structured phone interview of 

participants, which was conducted by trained interviewers using a computer-assisted 

telephone interviewing system. The phone interviews gauged care management in 

the following areas: 

 Advanced directive/living will. Each participant was asked whether he or she had 

an advanced directive, a living will, both, or neither. The participant’s response 

was coded as 1 if he or she had an advanced directive, a living will, or both in place 

or 0 if neither an advanced directive nor a living will was in place. 

 Pain management. Each participant was asked about the frequency and intensity 

of pain experienced during the past week. The participant’s response was coded 

as 1 if he or she reported pain that interfered with a normal routine (i.e., mild, 

moderate, or severe pain either some, most, or all of the time) or 0 if pain did not 

interfere with a normal routine. 

 Falls. Each participant was asked whether he or she had a fall in the past 6 months. 

The participant’s response was coded as 1 if he or she had a fall or 0 if he or she did 

not fall. 

 Unintended weight loss. Each participant was asked whether he or she had 

unintentionally lost 10 or more pounds in the past 6 months. The participant’s 

response was coded as 1 if he or she had lost 10 or more pounds unintentionally 

or 0 if he or she had not. 

 Unmet activities of daily living (ADLs) needs. Each participant was asked whether 

all needs for help had been met in regard to each of five ADLs: (1) getting around, 

(2) dressing, (3) bathing, (4) toileting, and (5) getting out of bed. Those who 
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reported that they did not receive help with a particular ADL were asked whether 

they needed any help they did not receive. Those who reported that they 

received help with an ADL were asked whether they needed more help than they 

received. For each ADL, these two variables were collapsed into a single measure, 

with a coding of 0 indicating no unmet ADL needs and 1 indicating an unmet need. 

Key Findings 

A study was conducted with older adults who were enrolled in PACE or in Medicaid 

home and community-based services (HCBS). All participants were assessed 

approximately 18 months to 5 years after enrollment in PACE or HCBS (first interview) 

and again approximately 1 year after the first interview (second interview). Findings 

indicated the following: 

 At the first interview, more PACE participants than HCBS participants had an 

advanced directive (p < .01), a living will (p < .05), both (p < .05), or either (p < .01) 

in place. At the second interview, more PACE participants than HCBS participants 

had an advanced directive (p < .05) or an advanced directive or a living will (p < 

.05) in place. 

 At the first and second interviews, fewer PACE participants than HCBS 

participants had pain that interfered with a normal routine (p < .01 and p < .05, 

respectively). 

 At the first interview, fewer PACE participants than HCBS participants had unmet 

needs in two ADLs: getting around (p < .05) and dressing (p < .01). At the second 

interview, fewer PACE participants than HCBS participants had unmet needs in 

three ADLs: getting around (p < .05), bathing (p < .01), and dressing (p < .05). 

 There were no significant between-group differences regarding falls and 

unintended weight loss. 

Studies Measuring 

Outcome Study 1 

Study Designs Quasi-experimental 

Quality of Research Rating 

(0.0–4.0 scale) 3.0 

Outcome 2: Health Status, Functioning, and Mental Health 

Description of Measures 

Health status, functioning, and mental health were assessed through a structured 

phone interview of participants (and, for one item, their caregivers), which was 

conducted by trained interviewers using a computer-assisted telephone interviewing 

system. The phone interviews gauged health status, functioning, and mental health in 

the following areas: 

 Self-rated health status. Each participant was asked to compare his or her health 

with that of other people the same age, using a scale ranging from 1 (poor health) 

to 5 (excellent health). Each participant then was asked to compare his or her 

current health with that from 1 year ago, using a scale ranging from 1 (much 

worse health) to 5 (much better health). 

 Activities of daily living (ADLs). Each participant was asked whether he or she had 

difficulty with completing each of five ADLs during the past week: (1) getting 
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around, (2) dressing, (3) bathing, (4) toileting, and (5) getting out of bed. 

Difficulty was defined as getting help from another person or needing but not 

getting help from another person. The participant’s response was coded as 0 if he 

or she had no difficulty or had independence (i.e., either performing the ADL on 

his or her own or with the use of an assistive device) or 1 if the ADL was done with 

difficulty (including not doing the ADL at all, receiving help from another person, 

or needing but not receiving help). 

 Depression. Each participant was asked whether he or she had any of four 

symptoms of depression in the past month: (1) felt down, depressed, or hopeless; 

(2) experienced little interest or pleasure in doing things; (3) worried a lot; or 

(4) felt keyed up or on edge. The participant’s response for each symptom was 

coded as 1 if he or she had the symptom or 0 if not. 

 Behavioral problems. Because of the high prevalence of cognitive impairment 

among residents of a nursing home and the association of cognitive impairment 

with behavioral problems, the interviewers asked proxy respondents (i.e., the 

participants’ caregivers) to gauge four problem behaviors in regard to the 

associated participant: (1) wandering, (2) delirium, (3) physical aggression, and 

(4) verbal aggression. Each proxy was asked whether the behavior occurs with 

the participant more than once a week, less than once a week, or never. The 

proxy’s response for each behavior was coded as 0 if the behavior never occurs 

or 1 if the behavior occurs (i.e., less than or more than once a week). 

Key Findings 

A study was conducted with older adults who were enrolled in PACE or in Medicaid 

home and community-based services (HCBS). All participants were assessed 

approximately 18 months to 5 years after enrollment in PACE or HCBS (first interview) 

and again approximately 1 year after the first interview (second interview). Findings 

indicated the following: 

 At the first interview, PACE participants had a better self-rated health status than 

HCBS participants (p < .01). Also at the first interview, PACE participants had a 

better self-rated health status compared with that from 1 year ago relative to 

HCBS participants (p < .01). 

 At the first interview, fewer PACE participants than HCBS participants had 

depressive symptoms in the past month in two areas of assessment: felt down, 

depressed, or hopeless (p < .01) and worried a lot (p < .01). At the second 

interview, fewer PACE participants than HCBS participants had depressive 

symptoms in the past month in one area of assessment: worried a lot (p < .01). 

 However, more PACE participants than HCBS participants experienced behavioral 

problems in one area of assessment at each interview: at the first interview, 

delirium (p < .05), and at the second interview, physical aggression (p < .01). 

 There were no significant between-group differences regarding ADLs. 

Studies Measuring 

Outcome Study 1 

Study Designs Quasi-experimental 

Quality of Research Rating 

(0.0–4.0 scale) 3.0 
6 

Outcome 3: Utilization of Health Services 

Description of Measures 

In one study, utilization of health services was assessed through a structured phone 

interview of participants, which was conducted by trained interviewers using a 

computer-assisted telephone interviewing system. The phone interviews gauged 

utilization of health services in the following areas: 

 Hospitalizations. Each participant was asked whether he or she had spent at least 

one night in a hospital in the previous year. The participant’s response was coded 

as 0 if he or she did not spend time in a hospital or 1 if he or she did. 

 Nursing home stays. Each participant was asked whether he or she had spent at 

least one night in a nursing home in the previous year. The participant’s 

response was coded as 1 if he or she did not spend time in a nursing home or 0 

if he or she did. 

 Hearing screening. Each participant was asked whether he or she has had a 

regular hearing check (at least once a year). The participant’s response was 

coded as 1 if he or she has had the screening (or is nonhearing) or 0 if he or she 

has not. 

 Vision screening. Each participant was asked whether he or she has had a regular 

vision check (at least once a year). The participant’s response was coded as 1 if he 

or she has had the screening (or is nonsighted) or 0 if he or she has not. 

 Influenza vaccine. Each participant was asked whether he or she had received a 

flu shot since the previous September. The participant’s response was coded as 1 

if he or she received the shot or 0 if he or she did not. Each participant also was 

asked whether he or she was offered a flu shot. The participant’s response was 

coded as 1 if he or she had access to a flu shot or 0 if he or she did not. 

 Pneumococcal vaccine. Each participant was asked whether he or she has ever 

had a pneumococcal vaccine. The participant’s response was coded as 1 if he or 

she has had the shot or 0 if he or she has not. 

In another study, utilization of health services (i.e., hospital use, defined as the 

average number of days per month that participants spent in a hospital) was assessed 

with data from two sources: 

 DataPACE, a public use data set providing information for individuals enrolled in 

PACE between June 1, 1990, and June 30, 1998. This information includes 

participants’ demographics, socioeconomics, health status and disability, medical 

history, utilizations of health services, and date of death. These data were 

collected by PACE program staff and include hospital-use data for as long as the 

enrollee remained in the program. 

 Medicare Current Beneficiary Survey (MCBS), a nationally representative 

longitudinal survey of the Medicare population. The MCBS contains up to 3 years 

of hospital-use data. 

Key Findings 

One study was conducted with older adults who were enrolled in PACE or in Medicaid 

home and community-based services (HCBS). All participants were assessed 

approximately 18 months to 5 years after enrollment in PACE or HCBS (first interview) 

and again approximately 1 year after the first interview (second interview). Findings 

indicated the following: 
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 At the first and second interviews, more PACE participants than HCBS 

participants indicated that they spent no time in a hospital in the previous year (p

< .01 and p < .05, respectively). 

 At the first and second interviews, more PACE participants than HCBS 

participants indicated that they spent no time in a nursing home in the previous 

year (p < .01 and p < .01, respectively). 

 At the first and second interviews, more PACE participants than HCBS 

participants indicated that they had hearing screening in the previous year (p < .01 

and p < .01, respectively). 

 At the first and second interviews, more PACE participants than HCBS 

participants indicated that they had vision screening in the previous year (p < .01 

and p < .01, respectively). 

 At the first and second interviews, more PACE participants than HCBS 

participants indicated that they had a recent flu shot (p < .01 and p < .01, 

respectively). In addition, at the first and second interviews, more PACE 

participants than HCBS participants indicated that they were recently offered a 

flu shot (p < .01 and p < .05, respectively). 

 At the first interview, more PACE participants than HCBS participants indicated 

that they had a pneumococcal vaccine (p < .01). 

Another study assessed hospital use by PACE enrollees and a control group of frail, 

community-dwelling older adults. Findings indicated that over a 2-year follow-up 

period, hospital use by PACE enrollees was less than that by older adults in the control 

group (0.2 vs. 0.8 days per month alive; p < .01). 

Studies Measuring 

Outcome Studies 1 and 3 

Study Designs Quasi-experimental 

Quality of Research Rating 

(0.0–4.0 scale) 3.3 

Outcome 4: Long-Term Survivability 

Description of Measures 

Long-term survivability was assessed with data from two sources: 

 DataPACE, a public use data set providing information for individuals enrolled in 

PACE between June 1, 1990, and June 30, 1998. This information includes 

participants’ demographics, socioeconomics, health status and disability, medical 

history, utilizations of health services, and date of death. These data were 

collected by PACE program staff. 

 Records from the South Carolina Long-Term Care Assessment Form 1718. State 

regional teams used this form to assess long-term-care applicants. The records 

include data describing the medical, psychosocial, functional, environmental, and 

social supports of entrants, including date of death. 

In addition, the PACE Prognostic Index (PPI) was used at admission to assess the 

mortality risk of all participants. PPI risk factors were weighted as follows: male sex 

(2 points); age 75–84 (2 points) or 85 or older (3 points); dependence in toileting 
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(1 point); dependence in dressing, partial (1 point) or full (3 points); malignant 

neoplasm (2 points); congestive heart failure (3 points); chronic obstructive 

pulmonary disease (1 point); and renal failure or insufficiency (3 points). All points 

were summed for each participant, and mortality risk was designated as low (0–3 

points), moderate (4 or 5 points), or high (5 or more points). Participant cohorts were 

then stratified by these risk levels. 

Key Findings 

A study was conducted with older adults who received services through PACE; 

received services through Community Choices, a Medicaid community-based waiver 

program; or were residents of a nursing home. Participants were followed for 5 years 

or until death. 

After stratification by risk level, PACE participants had a 5-year survival advantage 

over Community Choices participants (p = .015). Among participants with a high 

mortality risk, PACE participants had a longer median survival than Community 

Choices participants (3.0 years vs. 2.0 years; p = .01). Among participants with a 

moderate mortality risk, PACE participants also had a longer median survival than 

Community Choices participants (4.7 years vs. 3.4 years); however, this finding was 

not significant. 

Before stratification by risk level, PACE participants had a longer median survival than 

that of Community Choices participants or participants in a nursing home (4.2 years 

vs. 3.5 years vs. 2.3 years); however, this finding also was not significant. 

Studies Measuring 

Outcome Study 2 

Study Designs Quasi-experimental 

Quality of Research Rating 

(0.0–4.0 scale) 3.0 

Study Populations 

The following populations were identified in the studies reviewed for Quality of Research. 

Study Age Gender Race/Ethnicity 

Study 1 

 50–60 (Older adult) 

 61–74 (Older adult) 

 75–84 (Older adult) 

 85+ (Older adult) 

 75% Female 

 25% Male 

 52% Race/ethnicity 

unspecified 

 26% Hispanic or Latino 

 22% Black or African American 

Study 2 

 50–60 (Older adult) 

 61–74 (Older adult) 

 75–84 (Older adult) 

 85+ (Older adult) 

 68% Female 

 32% Male 

 55% Black or African American 

 45% Race/ethnicity 

unspecified 

Study 3 

 50–60 (Older adult) 

 61–74 (Older adult) 

 75–84 (Older adult) 

 85+ (Older adult) 

 72% Female 

 28% Male 

 67% White 

 33% Race/ethnicity 

unspecified 
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Quality of Research Ratings by Criteria (0.0–4.0 scale) 

Criterion 

Ratings 

Outcome 1 Outcome 2 Outcome 3 Outcome 4 

Reliability of 

Measures 2.3 2.3 2.9 3.7 

Validity of Measures 3.0 3.0 3.5 3.4 

Intervention 

Fidelity 3.0 3.0 2.5 2.5 

Missing Data and 

Attrition 3.0 3.5 3.8 2.5

Potential 

Confounding 

Variables 

2.5 2.5 3.0 2.0 

Appropriateness of 

Analysis 4.0 4.0 4.0 4.0

Overall Rating 3.0 3.0 3.3 3.0

Study Strengths 

The instruments used to assess long-term survivability have standardized protocols and acceptable reliability and 

validity. There is evidence of acceptable fidelity in the systematic collection of data, and guidelines were used for 

monitoring quality assurance procedures and facilitating the fidelity of the program. Two studies used good methods 

to account for attrition; for example, a weighted adjustment factor was used to account for attrition between initial 

and follow-up interviews. Sophisticated analyses and the large sample size allow relationships between the 

intervention and the outcomes to be inferred in all three studies. 

Study Weaknesses 

In one study, the questions used in the structured phone interview to assess some of the outcomes were not tested 

for reliability and validity. In all three studies, some confounding variables were not adequately addressed; for 

example, there was some incompatibility with the data collected from separate sites, and a proxy was used to collect 

data for one outcome. In addition, psychosocial factors were minimally addressed (e.g., effects of varying community 

settings, decreasing incidence of depression), which might affect the program’s impact on the outcomes.
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Review Date: June 2007 

Documents Reviewed 

The documents below were reviewed for Quality of Research. The research point of contact can provide 

information regarding the studies reviewed and the availability of additional materials, including those from 

more recent studies that may have been conducted. 

Study 1 

Chatterji, P., Bustein, N. R., Kidder, D., & White, A. (1998, July). Evaluation of the Program of All-Inclusive Care 

for the Elderly (PACE) demonstration: The impact of PACE on participant outcomes. Final report to the Health 

Care Financing Administration. Cambridge, MA: Abt Associates. 

Study 2 

Wieland, D., Lamb, V. L., Sutton, S. R., Boland, R., Clark, M., Friedman, S., ... Eleazer, G. P. (2000). Hospitalization 

in the Program of All-Inclusive Care for the Elderly (PACE): Rates, concomitants, and predictors. Journal of the 

American Geriatrics Society, 48(11), 1373–1380. PubMed abstract available at 

http://www.ncbi.nlm.nih.gov/pubmed/11083311

Williamson, J. D. (2000). Improving care management and health outcomes for frail older people: Implications of 

the PACE model. Journal of the American Geriatrics Society, 48(11), 1529–1530. PubMed abstract available at 

http://www.ncbi.nlm.nih.gov/pubmed/11083339

Study 3 

Massachusetts Division of Health Care Finance and Policy. (2005). PACE evaluation summary. Unpublished 

manuscript. 

Study 4 

Sands, L. P., Wang, Y., McCabe, G. P., Jennings, K., Eng, C., & Covinsky, K. E. (2006). Rates of acute care 

admissions for frail older people living with met versus unmet activity of daily living needs. Journal of the 

American Geriatrics Society, 54(2), 339–344. PubMed abstract available at 

http://www.ncbi.nlm.nih.gov/pubmed/16460389

Supplementary Materials 

Greenwood, R. (2001). The PACE model. Center for Medicare Education Issue Brief, 2(10), 1–7.

National PACE Association. (2001). State assessment of PACE: Tennessee. Alexandria, VA: Author. 

National PACE Association. (2001). State assessment of PACE: Texas. Alexandria, VA: Author. 

National PACE Association. (2003). Core resource set for PACE. Considerations for monitoring quality assurance 

across PACE centers. Alexandria, VA: Author. 

National PACE Association: How NPA Supports Its Members 
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PACE Expansion Initiative: Final Progress Report to the Robert Wood Johnson Foundation, January 1, 2001–July 

30, 2004 

PACE Quality: Overview of Assessments and Findings 

Outcomes 

Outcome 1: Utilization of Medical Services 

Description of Measures 

Utilization of medical services was analyzed using the following measures: 

 Hospital utilization: any inpatient hospital admission, number of inpatient hospital 

days, and length of stay 

 Nursing home utilization: any nursing home admission and number of nights 

spent in a nursing home 

 Utilization of ambulatory services: any ambulatory care visits (i.e., visits with doctors, 

therapists, or other medical professionals) and number of ambulatory visits 

 Emergency department utilization: total emergency department visits 

 Acute admission: an acute illness that prevented the patient from remaining at 

home and would have required a hospital admission 

Data for these measures were from the Abt Associates, Inc., survey of PACE 

participants and program sites; DataPACE, a comprehensive data collection system 

containing data from PACE programs; and the Massachusetts Division of Health Care 

Finance and Policy. 

Key Findings 

In several studies, PACE participants were compared to various other groups: older 

adults who expressed interest in PACE but decided not to enroll, individuals receiving 

Medicare due to age or disability, nursing home residents, and older adults who were 

eligible for nursing home care but were receiving care at home. PACE participants had 

significantly lower rates of hospital, nursing home, and emergency department 

utilization and lower overall rates of inpatient days than participants in the 

comparison groups (p = .01–.10). Meanwhile, PACE enrollees had higher utilization of 

ambulatory services than comparison group members. The size of the impact of PACE 

on these results decreased over time. 

Studies Measuring 

Outcome Studies 1–4 

Study Designs

 Quasi-experimental 

 Preexperimental 

Quality of Research Rating 

(0.0–4.0 scale) 2.4 

Outcome 2: Utilization of Support Services 

Description of Measures Utilization of support services was analyzed using the following measures: 
12

 Utilization of an adult day center: any attendance of an adult day center and 

frequency of attendance of an adult day center (times per week) 

 Utilization of home nurses: any home visits from a nurse and number of visits 

from a nurse in the past 6 months 

 Receipt of formal care: receipt of any formal (paid) care and receipt of formal 

care at least five times per week 

Data for these measures were from the Abt Associates, Inc., survey of PACE 

participants and sites. 

Key Findings 

PACE participants were far more likely to attend adult day centers and less likely to 

need any home visits by a nurse than comparison group members (individuals who 

expressed an interest in PACE but decided not to enroll) (p < .05). Meanwhile, the 

likelihood and intensity of formal care services were higher in the comparison group 

than among PACE participants, but the difference was not statistically significant. 

Studies Measuring 

Outcome Study 1 

Study Designs Quasi-experimental 

Quality of Research Rating 

(0.0–4.0 scale) 2.5 

Outcome 3: Perceived Health Status, Functional Status, and Overall Quality of Life 

Description of Measures 

To measure the impact of PACE on perceived health status and overall quality of life, 

participants (or their proxy respondent) were asked questions to determine, for 

example, whether the participant was in good or excellent health; whether the 

participant’s life was satisfying; and whether the participant attended social, religious, 

or recreational programs at least once a week. For functional status, participants (or 

their proxy respondent) were asked about their activities of daily living (ADL) and 

instrumental activities of daily living (IADL) limitations (e.g., whether the participant 

had a behavioral problem, the number of ADL limitations, the number of IADL 

limitations, and whether the participant used an assistive device). 

Key Findings 

PACE participants reported better health status and quality of life and less 

deterioration in physical function than comparison group members (individuals who 

expressed an interest in PACE but decided not to enroll) (p = .01–.10). These effects 

were most dramatic during the first 6 months of enrollment in PACE. 

Studies Measuring 

Outcome Study 1 

Study Designs Quasi-experimental 

Quality of Research Rating 

(0.0–4.0 scale) 2.5 
13

Outcome 4: Mortality Rate 

Description of Measures To measure the impact of PACE on mortality, data from Medicare enrollment records 

were used. The observation period for the analysis sample ranged from 11 days to 2.5 years. 

Key Findings 

Over the course of the observation period, 19% of PACE enrollees died, compared with 

25% of comparison group members (individuals who expressed an interest in PACE 

but decided not to enroll) (p = .03). 

Studies Measuring 

Outcome Study 1 

Study Designs Quasi-experimental 

Quality of Research Rating 

(0.0–4.0 scale) 2.5 

Outcome 5: Comorbidity Diagnoses 

Description of Measures 

Comorbidity diagnoses were measured using the average number of diagnoses per 

discharge. The data were from the Massachusetts Division of Health Care Finance 

and Policy. 

Key Findings 

One study compared PACE participants to two other groups: a waiver group 

consisting of people eligible for nursing home care but receiving care at home and a 

group of nursing home residents. Overall, the PACE group and waiver group had 

slightly fewer diagnoses per discharge (8.41 and 8.49, respectively) than the nursing 

home group (9.09). 

Studies Measuring 

Outcome Study 3 

Study Designs Quasi-experimental 

Quality of Research Rating 

(0.0–4.0 scale) 2.3 

Study Populations 

The following populations were identified in the studies reviewed for Quality of Research. 

Study Age Gender Race/Ethnicity 

Study 1 

 50–60 (Older adult) 

 61–74 (Older adult) 

 75–84 (Older adult) 

 85+ (Older adult) 

 69% Female 

 31% Male 

 46% Race/ethnicity 

unspecified 

 33% Black or African American 

 21% Hispanic or Latino 

Study 2  50–60 (Older adult) 

 61–74 (Older adult) 

 71% Female 

 29% Male 

Data not reported/available
14

 75–84 (Older adult) 

 85+ (Older adult) 

Study 3 

 50–60 (Older adult) 

 61–74 (Older adult) 

 75–84 (Older adult) 

 85+ (Older adult) 

Data not reported/available Data not reported/available

Study 4 

 50–60 (Older adult) 

 61–74 (Older adult) 

 75–84 (Older adult) 

 85+ (Older adult) 

 70% Female 

 30% Male 

 51% White 

 20% Black or African American 

 17% Asian 

 10% Hispanic or Latino 

 2% Race/ethnicity unspecified

Quality of Research Ratings by Criteria (0.0–4.0 scale) 

Criterion 

Ratings 

Outcome 1 Outcome 2 Outcome 3 Outcome 4 Outcome 5 

Reliability of 

Measures 2.5 2.5 2.5 2.5 2.5 

Validity of Measures 2.5 2.5 2.5 2.5 2.5 

Intervention Fidelity 2.0 2.0 2.0 2.0 2.0 

Missing Data and 

Attrition 2.0 2.5 2.5 2.5 1.5 

Potential 

Confounding 

Variables 

2.0 2.0 2.0 2.0 2.0 

Appropriateness of 

Analysis 3.4 3.5 3.5 3.5 3.5 

Overall Rating 2.4 2.5 2.5 2.5 2.3 

Study Strengths 

A training manual that defined measures and training procedures was used to ensure adequate psychometric 

properties. The program showed basic fidelity and national program support for implementation. Analyses were 

thoughtful, appropriate, and well done. 
15

Study Weaknesses 

The methods of gathering information left questions about the data’s accuracy. The comparison groups, when 

present, were convenience controls and limit inferences of causation to the outcomes. Attrition and missing data 

were often not addressed fully. 

Readiness for Dissemination 

Review Date: June 2007 

Materials Reviewed 

The materials below were reviewed for Readiness for Dissemination. The implementation point of contact can 

provide information regarding implementation of the program and the availability of additional, updated, or 

new materials. 

Greenwood, R. (2001). The PACE model. Center for Medicare Education Issue Brief, 2(10), 1–7.

National PACE Association. (2002). Business planning checklist for new PACE programs. Alexandria, VA: Author. 

National PACE Association. (2003). Core resource set for PACE. Considerations for monitoring quality assurance 

across PACE centers. Alexandria, VA: Author. 

National PACE Association. (2006). PACE medical director’s handbook. Alexandria, VA: Author. 

National PACE Association. (n.d.). A guide to preparing the PACE provider application. Alexandria, VA: Author. 

PACE Web site, http://www.npaonline.org

Readiness for Dissemination Ratings by Criteria (0.0–4.0 scale) 

Criterion Rating 

Implementation Materials 4.0

Training and Support 4.0

Quality Assurance 4.0

Overall Rating 4.0 

Dissemination Strengths 

The program materials include a comprehensive set of core resources providing guidance for starting, administering, 

and operating the PACE program. Program materials also include tips for partnering with State and Federal 
16

governments. High quality training and support resources are available online and through membership with the 

National PACE Association. Protocols for standardized implementation and oversight by the medical director are 

provided to support quality assurance. 

Dissemination Weaknesses 

Most of the detailed guidance documents are available only to members of the National PACE Association. Given the 

complexity of this model, it would be necessary to join this association in order to benefit from its work and that of its 

other members. 

Costs 

The cost information below was provided by the developer. Although this cost information may have been 

updated by the developer since the time of review, it may not reflect the current costs or availability of items 

(including newly developed or discontinued items). The implementation point of contact can provide current 

information and discuss implementation requirements. 

Implementation Materials 

Item Description Cost 

Required by 

Developer 

Exploring PACE membership $3,000 per organization 

Yes 

(one membership 

option is required) 

Prospective provider membership $11,400 per organization 

Yes 

(one membership 

option is required) 

Provider membership 

$15,000 per organization, 

plus additional fees based 

on organization’s revenue 

Yes 

(one membership 

option is required) 

Training, technical assistance, consultation, and quality 

assurance materials Contact the developer Contact the developer 

Additional Information 

The start-up cost for each facility differs for a multitude of reasons, such as the cost of the lease of the building, 

the size of the facility, construction costs, consulting fees, equipment that must be purchased for everyday 

operations, transportation and vehicle costs, working capital, and solvency requirements. Total start-up costs 

can range from $1.5 million to over $5 million, depending on the size and location of the program. 

PACE programs receive Medicare and Medicaid dollars to support the costs of services; in 2013, the Medicare 

and Medicaid capitation rate averages (per member, per month) were $2182.09 and $3,402.65, respectively. 
17

Other Citations 

Hirth, V., Baskins, J., & Dever-Bumba, M. (2009). Programs of All-Inclusive Care (PACE): Past, present, and future.

Journal of the American Medical Directors Association, 10(3), 155–160. PubMed abstract available at 

http://www.ncbi.nlm.nih.gov/pubmed/19233054

Kane, R. L., Homyak, P., Bershadsky, B., & Flood, S. (2006). Variations on a theme called PACE. Journals of 

Gerontology Series A: Biological and Medical Sciences, 61A(7), 689–693. PubMed abstract available at 

http://www.ncbi.nlm.nih.gov/pubmed/16870630

Translational Work 

PACE programs are comprehensive community-based care models for frail, chronically ill older adults who are 

eligible for a nursing home because of their medical impairments. As such, Medicare and Medicaid programs 

have recognized the PACE model as a provider type since the 1990s, facilitating the expansion of PACE programs 

throughout the United States. The National PACE Association (NPA) provides a series of developmental

opportunities to PACE organizations, including monthly informational teleconference calls with NPA members in 

PACE organizations; an interdisciplinary online training program designed to support PACE organizations in 

creating, training, and maintaining interdisciplinary teams; and annual conferences, forums, and summits. NPA 

supports the expansion of PACE by providing implementation resources to States through the Accelerating State 

Access to PACE (ASAP) program. The ASAP program is a grant-funded initiative providing direct training, 

technical assistance, and funding to States in order to expand the capacity of PACE. The growth of PACE 

programs has been documented in evaluation reports, case studies, and demonstration projects highlighting the 

strengths and limitations of implementation. 

Providence ElderPlace in Portland, Oregon, was one of the first PACE sites. The PACE model has been 

successfully implemented to create Providence ElderPlace’s Supportive Care Program, which provides palliative 

care. The Supportive Care Program is sustained by an interdisciplinary team with the goals of providing support 

and medical management to the Providence ElderPlace participants, easing participants’ physical and emotional 

symptoms, and helping family members and caregivers through the bereavement process. A supportive care 

steering committee oversees program management and initiates improvements. Positive outcomes facilitated 

by the Supportive Care Program include an increase in the number of Providence ElderPlace participants who 

have a supportive care plan in place at their time of death, a decrease in the number of intensive care unit 

admissions in the last year of a participant’s life, an increase in the percentage of participants who choose to 

remain in their place of residence until they die, and high satisfaction rates among participants’ surviving family 

members with the end-of-life care provided to the participants. Program success has been attributed to the 

strong collaboration between Providence ElderPlace and caregivers from adult care, residential care, and 

assisted living organizations. 

In 2001–2003, the PACE model was evaluated in three Veterans Affairs (VA) medical centers using three allinclusive care models: a VA medical center in Ohio as the sole health care provider (Model I), a partnership 

between a VA medical center and a PACE provider in Colorado to share care responsibilities (Model II), and a 

contract generated by a VA medical center with a community PACE provider in South Carolina to provide all 

health care to veterans (Model III). The program evaluation examined health care utilization rates among 368 

veterans 6 months before enrollment and 6–36 months after enrollment across the all-inclusive care programs. 
18

Findings indicated that participants in Models II and III, which included a partnership with PACE, had higher 

utilization rates of adult day health care compared with participants in Model I. Participants in Model III had 

higher rates of nursing home use and home care use 6 months after enrollment compared with participants in 

Models I and II. In addition, findings demonstrated that the VA medical centers were able to successfully 

implement three variations of all-inclusive care models with veterans. 

PACE of the Triad is a nonresidential facility serving the greater Greensboro, North Carolina, region. The facility 

provides hospice care, on-site medical care, adult day care services, home health care, medication, and 

transportation services through a partnership initiated in 2008 with a health system, a home health agency, a 

retirement community, and a hospice. The partnership began through the development of a steering committee 

to guide the planning, feasibility, and evaluation process to ensure that PACE was a suitable program for the 

region. Through grant funding from the health system, a marketing assessment and business plan were 

developed through consultation with a senior care research organization. The partnership recognizes that the 

start-up phase was very challenging, but the mutual team goal of improving the quality of care for frail older 

adults in the community was a powerful force to help overcome challenges. As of May 2011, PACE of the Triad 

began accepting applicants to receive services. All partners have contracts with PACE of the Triad to provide 

specific patient care services, and all partners are currently focused on ensuring long-term sustainability. 

Site With 

Translational 

Work 

Articles Describing Site’s Translational Work, by Category 

Planning/ 

Partners Adoption 

Reach/ 

Recruitment Implementation Effectiveness Maintenance 

Providence 

ElderPlace, 

Portland, OR 

Article 1 Article 1 — Article 1 Article 1 Article 1 

3 VA medical 

centers (in OH, 

CO, and SC) 

Article 2 Article 2 Article 2 Article 2 — —

PACE of the 

Triad, 

Greensboro, NC 

Article 3 Article 3 — — — —

Article 

Number Article Reference 

1 

Lee, M., & Booth, S. (2008). The PACE program and end-of-life care. Providence ElderPlace in 

Portland, Ore., develops unique approach for enrolled participants. Health Progress, 89(3), 62–66. 

PubMed abstract available at http://www.ncbi.nlm.nih.gov/pubmed/18488705

2 

Weaver, F. M., Hickey, E. C., Hughes, S. L., Parker, V., Fortunato, D., Rose, J., ... Baskins, J. (2008). 

Providing all-inclusive care for frail elderly veterans: Evaluation of three models of care. Journal of 

the American Geriatrics Society, 56(2), 345–353. PubMed abstract available at 
19

http://www.ncbi.nlm.nih.gov/pubmed/18070006

3 

Hospice and palliative care of Greensboro: Partnering to provide PACE. (2011, December). NewsLine. 

Retrieved from http://www.advhomecare.org/wp-content/uploads/PACEarticle_NHPCO.pdf

Contacts 

To learn more about implementation or research, contact: 

Shawn M. Bloom 

National PACE Association 

(703) 535-1567 

shawnb@npaonline.org

Teresa Belgin 

National PACE Association 

(703) 535-1518 

teresab@npaonline.org

Additional program information can be obtained through the following Web site: 

http://www.npaonline.org

This intervention summary was developed through funding from the Administration for Community Living (ACL), 

Administration on Aging (AoA). The summary contains information from the Quality of Research and Readiness 

for Dissemination reviews that were completed in June 2007 and October 2012 for the intervention summary 

developed by the National Registry of Evidence-based Programs and Practices (NREPP), which is funded by the 

Substance Abuse and Mental Health Services Administration (SAMHSA).