Definition/Introduction

The Program of All-Inclusive Care for the Elderly (PACE) is a government-funded healthcare model for individuals aged 55 or older who need nursing home–level care due to chronic illnesses. Founded in San Francisco in 1971, PACE has become a key part of community-based, integrated care for older adults across the United States. Using a capitated payment system, PACE provides a full range of care and services to help older adults live safely in their communities for as long as possible, avoiding over-institutionalization and saving healthcare dollars. PACE not only leads to shorter, fewer hospital stays but also greatly improves the quality of life for older adults with chronic health conditions.[1][2][3][4][5][6] Eligible individuals can often gain up to 4 additional years of independence and a high quality of life within their own community through PACE programs. [7]

As of September 2025, 194 organizations operate over 376 centers, serving approximately 87,000 participants. Approximately 94% of participants live in the community, 80.5% are dually eligible for Medicare and Medicaid, 19% are enrolled in Medicaid alone, and 0.4% pay a premium (through Medicare or other payers).[National PACE Association] PACE has proven itself to be a cost-effective program for improving the last chapter of life for older patients and is continuing to expand nationwide. 

Issues of Concern

The PACE is a government-funded healthcare model in the United States specifically designed for community-dwelling older adults with long-term healthcare needs. PACE offers comprehensive healthcare services, including primary care; specialty medical care, such as audiology, dentistry, optometry, and podiatry; nursing; various therapies, including occupational, physical, recreational, and speech; pharmaceuticals; nutritional support; meals; behavioral health services; social services; day health centers; home care; respite care; health-related transportation; disability services; and end-of-life care. In addition to the wide range of care provided, the PACE model can expand its services to include other medically necessary treatments that help improve participants' health.[1]

The PACE model was developed for older adults with chronic medical conditions and their families. PACE's goal is to help these individuals maintain their independence within their community for as long as possible. This innovative, accessible, and effective care model successfully promotes independence for people with substantial healthcare needs and is widely regarded as the gold standard for community-based integrated care.[1] According to the Centers for Medicare & Medicaid Services (CMS), the PACE provider-sponsored health plan model is considered the future of older adult care in the United States as it combines medical, behavioral, and social care for individuals with chronic illnesses.[4]

PACE operates on the principle that older adults with chronic illnesses are best served in their communities whenever feasible. Individuals aged 55 or older who are certified by their state as needing nursing home–level care, can live safely in the community at the time of enrollment, and reside within a PACE service area are eligible for enrollment.[8][5] Once enrolled, participants can remain in the program through the end of their lives, as long as they maintain functional and financial eligibility. The PACE organization cares for and adapts to patients' evolving medical needs, including adding palliative and end-of-life services when appropriate. The average PACE participant closely resembles a nursing home resident. Most are older adults with 8 or more medical conditions, and dependencies or limitations in 3 activities of daily living. Nearly half of PACE participants have been diagnosed with dementia.[6] Despite their high care needs, over 90% of PACE participants can continue living in their community with a good quality of life.[7] 

PACE participants receive:

• Adult daycare with nursing, physical and occupational therapies, meals, nutritional counseling, recreational activities, social work, and personal care
• Medical care provided by a PACE physician attuned to the participant's unique history, needs, and preferences
• Home health care and personal care
• All necessary prescription drugs
• Social services
• Medical specialties, such as audiology, dentistry, optometry, podiatry, and speech therapy
• Respite care
• Hospital and nursing home care when necessary
• End-of-life care when necessary

The PACE model was developed in the 1970s in the San Francisco Chinatown-North Beach region to address the need for long-term services tailored for seniors from immigrant families. A committee led by William Gee, DDS, a dentist specializing in public health, founded the nonprofit Chinatown-North Beach Health Care Planning and Development Corporation and appointed Marie-Louise Ansak, a visionary pioneer and innovator in senior care. Through her research, Ansak identified that conventional nursing home models are neither financially sustainable nor culturally appropriate for the community's requirements. Consequently, she partnered with the University of California, San Francisco, to train healthcare personnel. Drawing inspiration from the British day hospital model, she developed a healthcare system that combined housing, medical, and social services. The original initiative was eventually renamed On Lok Senior Health Services, with the term On Lok meaning "peaceful, happy abode" in Cantonese.

The National PACE Association (NPA), established in 1994, advances and supports the PACE model of care.[1] The organization collaborates with Congress, senior administration officials, and policymakers to foster an environment conducive to the growth and sustainability of PACE programs, ensuring the continued delivery of high-quality, individualized, and innovative care. Additionally, the NPA partners with other entities to advocate for enhancing the PACE healthcare system's capacity to deliver appropriate care and to support the efforts of families, friends, and caregivers in assisting older adults residing in the United States.

The PACE model was formally recognized by CMS as a provider type under the Balanced Budget Act of 1997.[1] Following the publication of the Final Regulation in 2006, Congress awarded grants to expand PACE in rural areas. The PACE Innovative Act was enacted by Congress in 2015 and subsequently signed into law by President Barack Obama. The PACE Final Rule was published in 2019.

The PACE model continues to grow in the United States. Building upon resources developed through the NPA PACE 2.0 initiative, the Alliance for PACE Innovation and Quality offers support and consultation to organizations interested in establishing and maintaining PACE programs, supported by grants from The John A. Hartford Foundation, West Health, and The Harry and Jeanette Weinberg Foundation.[1] These organizational efforts and funding opportunities have facilitated the expansion of PACE from the pioneering On Lok Senior Health Services to 194 organizations operating 376 centers, serving approximately 87,000 participants.[National PACE Association] 

Nonetheless, despite the ongoing expansion of the PACE healthcare model in the United States, its availability remains limited predominantly along the East Coast. With over 10,000 individuals aging into the older adult population daily, further expansion of the PACE model is essential to meet this demographic growth.[4][5] Financial barriers may also hinder accessibility to PACE, contingent upon an individual's eligibility for Medicare and Medicaid.[6] To qualify for Medicare, individuals must be aged 65 or older or have a qualifying disability. Medicaid qualification requires proof of low income and resources. Individuals with Medicare but not Medicaid are responsible for monthly premiums and medication costs. Individuals who are not eligible for both programs bear the costs for long-term care services and Medicare Part D premiums.

The COVID-19 pandemic underscored the challenges faced by the PACE model, particularly those related to infection control and staffing shortages.[7] Most PACE participants are frail older adults who frequently live with multiple disabilities and chronic conditions. Consequently, PACE organizations encountered unique challenges during the COVID-19 pandemic, including social distancing and infection control protocols. As a result, PACE organizations were compelled to temporarily suspend certain center-based services and transition towards providing most services within participants' homes through various strategies, which include the following:[9]

• Altering the mode of care delivery: A significant majority of PACE organizations (78.4%) closed their day centers at some point during the pandemic, with a median closure duration of 8 months. This measure was driven by concerns regarding participant safety and directives from state and local authorities. Nevertheless, PACE center medical clinics continued to deliver services via telehealth and a variety of remote and in-person approaches. The proportion of organizations with closed day centers reached its peak during the first half of May 2020 at 65%. Notably, by May 2022, responding PACE organizations had reopened their day centers, predominantly operating at limited capacity.[9]

• Adapting to new norms: Adaptations encompassed increasing in-person care delivery while enhancing safety measures in response to COVID-19, as well as augmenting food and nutrition services within participants' homes.[9]

• Delivering more in-person services and supports at home: According to reports, 95.5% of PACE organizations experienced an increase in in-home personal care, 84.1% expanded home health visits, and 58.0% increased in-person wellness checks. A substantial majority (94.2%) of PACE organizations successfully transitioned to in-home care in 2020 by redeploying staff previously engaged in the day center. Subsequently, home-based staff provided nursing and primary care services; personal and home health care; physical, occupational, and speech therapy; and medication management. Social support services remained available.[9]

• Leveraging telehealth and technology: Responses indicated that 90.9% of PACE organization representatives reported an increase in wellness check-ins via phone, 85.2% increased utilization of telehealth for condition treatment, 77.3% employed virtual care planning, 71.6% utilized remote assessments, 55.7% provided virtual behavioral health services, 48.9% used telehealth for condition diagnosis, and 40.9% offered virtual physical or occupational therapy. Additionally, PACE organizations delivered behavioral health services (72.4%), nutrition counseling (63.9%), rehabilitation services (43%), primary care (39.5%), and medication assistance (32.4%).[9]

• Expanding participant safety efforts: PACE directors implemented a variety of strategies to maintain participant safety. These strategies included increasing infection prevention and vaccine education (80.7%), modifying the intake and enrollment processes to build relationships with new participants outside the center (61.4%), developing partnerships to facilitate vaccine access (52.3%), deploying mobile vaccine units (44.3%), and enhancing laundry services (26.1%). Additionally, some PACE centers permitted overnight stays as alternatives to hospital admissions and nursing home placements—measures that were sanctioned by CMS and certain state and local agencies during the pandemic under specific conditions.[9]

• Preventing boredom and social isolation: Measures to promote mental stimulation and social interaction during the pandemic included sending activity kits to participants' homes (83%), increasing efforts to monitor mental health and social isolation (62.5%), and engaging participants through technology for communication or recreation (59.1%).[1][9]

Clinical Significance

The PACE has demonstrated superiority in providing comprehensive medical care to the vulnerable older population compared to the traditional health care system. Participation in a PACE program can reduce health care costs for national payers, improve quality of life, prevent institutionalization, and increase the services available to individual participants, including home care, social and recreational services, meal services, transportation services, and multiple therapies. Additionally, it provides a strong sense of community for the vulnerable older population who could otherwise face increasing isolation. The program's popularity across the United States is increasing as studies continue to demonstrate that older adults living with chronic illnesses are better served within their communities.[1][2][3][4][5][6] PACE serves a specific population: individuals aged 55 or older who are certified by their state as requiring nursing home care, those who are capable of living safely within their communities at the time of enrollment, and those who reside within a PACE service area.[7] The average participant in PACE is comparable to a nursing home resident, with an average of 8 medical conditions and limitations or dependencies in 3 activities of daily living, and a 50% likelihood of having dementia.[10] Upon enrollment, each participant undergoes an assessment conducted by an interdisciplinary team, which collaborates with the participant to develop an individualized care plan and coordinate person-centered care.[9][11] Despite high care needs, over 90% of PACE participants continue to reside in their communities with a good quality of life.[2][2]

PACE is regarded as the gold standard for community-based integrated care for older adults with chronic illnesses in the United States. This program is imperative to consider PACE as a healthcare option for adults aged 55 or older with chronic medical conditions who are eligible for nursing home care. This model is cost-effective and associated with lower hospitalization rates, shorter hospital stays, reduced caregiver burden, and an enhanced quality of life.[1][2][3][4][5][12][13][14] When a patient qualifies for both Medicare and Medicaid, this comprehensive level of care is accessible and results in substantial savings for CMS.[7][14][15] 

From a population health perspective, PACE programs are essential for addressing challenges faced by the broader healthcare system. The proportion of the US population aged 65 or older is expected to nearly double, from 52 million to 95 million, by 2060. This average patient in this age group has very complex medical needs and multiple chronic conditions requiring medical care and coordination. The availability of primary care providers is limited, and the system is increasingly overwhelmed with need, especially in rural and underserved areas. Emergency rooms are also facing increasing strain. A study demonstrated that 47% of patients with complex medical needs have visited the emergency department for an illness that could have been treated in a doctor's office or clinic.[3] PACE addresses these needs directly by providing both preventive and acute care to a population that often lacks the resources or ability to navigate the health care system independently.[6] 

Nursing, Allied Health, and Interprofessional Team Interventions

PACE represents a model for government-funded programs in the United States that delivers the entire spectrum of healthcare services to older adults with chronic illnesses, enabling them to remain safely within their communities rather than becoming institutionalized. An interprofessional team oversees the coordination of care to realize this innovative approach and provide holistic care. These healthcare professionals have expert-level experience working with older adults and collaborate closely with participants and their families to develop personalized, effective care plans. This close cooperation has been associated with increased primary care contact, higher survival rates, improved functional status, and enhanced quality of life, as evidenced by increased social interaction and reduced depression rates.[1][2][3] 

The PACE workforce includes roles essential to the interdisciplinary team and may also incorporate several non-mandated roles, such as chaplains and behavioral health specialists. The 11 CMS-mandated roles include primary care physician, nurse, social worker, physical therapist, occupational therapist, recreational therapist, dietitian, PACE center director, transportation coordinator, personal care worker, and home care coordinator.[4]

The interdisciplinary team approach has demonstrated considerable success in enhancing patient outcomes. Research indicates that PACE offers accessible, high-quality, and cost-efficient community-based care management to older adults who might otherwise require institutionalization in a nursing facility.[5] In relation to healthcare resource utilization, reviews have demonstrated that the average PACE participant experienced lower hospitalization rates, fewer readmissions, and fewer potentially avoidable hospitalizations than comparable populations, with shorter hospital stays (less than 6 days) within 12 months compared to other programs.[6][1][2][7][10][12] Participants enrolled in PACE not only experienced a reduction in hospitalizations but also showed improvements in both mental and physical health, enabling them to reside in the community for an additional 4 years on average and maintain a significantly higher quality of life, while caregivers reported decreased stress.[5][13][1][2][7][3] 

Furthermore, during the COVID-19 pandemic, which disproportionately affected older adults and those enrolled in long-term senior care, PACE demonstrated its ability to mount a COVID-19 response that prioritized safety, promoted the physical and mental well-being of its enrollees, and addressed the needs of caregivers through the interprofessional PACE care team.[16]  The PACE model facilitates both the education and training of multiple professional learners, such as nurses, therapists, physician assistants, medical residents, and fellows, as well as quality improvement and research initiatives, with studies being conducted and implemented by an interprofessional team to tackle common aging issues such as falls and poor oral hygiene.[14][15][17] Regarding costs, PACE's capitated payment system proved more cost-efficient than expenditures for comparable patients receiving alternative care, thereby generating significant savings for Medicaid.[11][18]

PACE coordinates the intricate care requirements of older adults with multiple chronic conditions, often encompassing behavioral health comorbidities. Participants in PACE exhibit a high prevalence of behavioral health conditions, including mental health diagnoses and substance use disorders. In 2014, the NPA reported that 59% of PACE participants had at least 1 behavioral health condition. The most common reasons for referral to behavioral health specialists include depression and mood disorders at 92.1%, behavioral and psychological symptoms of dementia at 57.9%, anxiety disorders at 55.3%, psychotic disorders such as schizophrenia or schizoaffective disorder at 36.9%, substance use disorders at 31.6%, post-traumatic stress disorder at 10.5%, and personality disorders at 7.9%.

Although members of the interdisciplinary team, such as primary care physicians and social workers, may be involved in behavioral health provision, the team does not include dedicated behavioral health specialists, such as psychiatrists, psychologists, or psychiatric nurse practitioners, or physician assistants. PACE organizations have reported innovative workforce configurations, including employing a social worker primarily providing behavioral health services (47.4%), a counselor (44.7%), a psychiatric mental health nurse practitioner or physician assistant (34.2%), a psychiatrist (21.0%), and a psychologist (15.8%). Furthermore, PACE organizations have established external partnerships, community networks, chaplaincies, and collaborations with academic institutions to address workforce shortages.[4]

Nursing, Allied Health, and Interprofessional Team Monitoring

The interprofessional team is the central component of PACE's care. The interdisciplinary team includes the 11 mandated professions—primary care physician, nurse, social worker, physical therapist, occupational therapist, recreational therapist, dietitian, PACE center director, transportation coordinator, personal care worker, and home care coordinator, as well as additional professionals. PACE offers all medically necessary services covered by Medicare, as well as additional services deemed necessary by the interdisciplinary team. The interdisciplinary team serves as the approving body for the program and is comprised of professionals who also directly provide patient care, facilitating the interdisciplinary team's intimate knowledge of what each participant truly benefits from. Healthcare professionals in the PACE organization and interdisciplinary team communicate regularly with participants and their caregivers to coordinate care across various settings, including the participants' homes, communities, PACE centers, hospitals, and nursing homes. Many PACE enrollees receive most of their care from this interdisciplinary team and additional staff employed by the PACE organization.[2][12][3]

The PACE Center serves as the central hub for care coordination and includes the Adult Day Health Center, where participants receive individualized care. Attendance at the center is generally 2 to 3 days per week. During visits, participants have access to primary medical care providers, social workers, and rehabilitation staff. They also receive personal care services as needed, along with transportation to and from the center. Home care services, including skilled nursing and personal care, are provided based on assessments of the interdisciplinary team.[8] 

The PACE model fosters continuous collaboration among participants, their families and caregivers, primary care physicians, the entire PACE staff, and other care providers to facilitate shared decision-making. This model grants the interdisciplinary team comprehensive oversight of patient outcomes and total care costs, and most notably, enables participants to live safely within the community.[5] The model assures enrollees that all decisions are protected between the participant and the interdisciplinary team. The interdisciplinary team is required to provide all services covered by traditional Medicare but may also offer additional services at its discretion, fostering creative problem-solving and improving health outcomes for the vulnerable older population whose needs may not be fully met by traditional health care. 

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Disclosure: Carla Williams declares no relevant financial relationships with ineligible companies.

Disclosure: Victoria Angela Morales declares no relevant financial relationships with ineligible companies.

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Disclosure: Soumya Chandrasekaran declares no relevant financial relationships with ineligible companies.