Program of All-Inclusive Care (PACE) Model

Abstract

The Program of All-inclusive Care of the Elderly (PACE), a community-based alternative to a skilled nursing facility, is recognized as an effective model of person-centered care for individuals with multiple chronic conditions and functional and/or cognitive impairments. In early 2014, 104 PACE programs served over 31,000 PACE participants nationally. PACE enrolls individuals 55 years of age or older who meet Medicaid eligibility criteria for nursing home level of care. Most are dually eligible for Medicare and Medicaid. The heart of the PACE model is the PACE Interdisciplinary Team, whose members include physicians, nurses, social workers, rehabilitation therapists, home care coordinators, and others involved in care. Integral to PACE are comprehensive assessment, comprehensive care planning with proactive monitoring, communication and coordination of professionals involved in care, and active engagement of individuals and their family caregivers in care. PACE has capitated financing with assumption of full financial risk for all services, receiving payments from Medicare, Medicaid, and/or individuals based on participant’s eligibility. Positive outcomes include improved health status, maintained functional status, lower inpatient utilization, high consumer satisfaction, and continued community residence. As a provider-based managed care organization, PACE encompasses many principles in Affordable Care Act initiatives: a health home for primary care and coordinating all aspect of care, a focus on prevention with close monitoring and early intervention to prevent exacerbation of chronic conditions, and full accountability for care cost and quality.