What To Know About PACE Programs For All-Inclusive Senior Care
The Program of All-Inclusive Care for the Elderly (PACE) is designed to offer comprehensive health services for seniors living in the community who would otherwise qualify to live in a nursing facility. For many older adults with complex health needs, managing multiple providers, medications, and care settings can feel overwhelming. PACE brings together medical care, social services, and daily support under one coordinated model, allowing seniors to age in their homes rather than institutions.
The PACE model of care is designed to help older adults remain in their home in the community for as long as possible, and provides both medical and social services and is a welcome alternative to nursing home care for many older adults. If you or a loved one is exploring long-term care options, understanding how PACE works—and whether it's a good fit—can help you make informed decisions about aging in place.
Understanding the PACE Model
PACE puts in place an integrated model of care that is specific to each senior, and this level of customization improves health outcomes not just for the seniors who enroll, but for the overall community. Rather than piecing together separate doctors, therapists, and social workers, PACE participants receive care from a single, coordinated team that works together on a shared care plan.
A PACE organization is responsible for providing care that meets the needs of each participant across all care settings, 24 hours a day, every day of the year, and services must be furnished in at least the PACE center, the home, and inpatient facilities. This continuous availability means that seniors have support whenever they need it, whether at home, during community activities, or in a hospital setting.
The PACE center includes a primary care clinic and areas for therapeutic recreation, restorative therapies, socialization, personal care, and dining, and serves as the focal point for coordination and provision of most PACE services. The center functions as a hub where participants can spend time engaging in activities, receiving therapy, and connecting with other seniors while remaining close to home.
Who Can Enroll in PACE?
To participate in PACE, a person must be 55 years of age or older, require nursing home level of care but be able to live safely in the community at the time of enrollment with the services of PACE, and reside in the service area of a PACE organization. Not every area has a PACE program available, so geographic location is an important first step in determining eligibility.
The assessment process is thorough to ensure that PACE is an appropriate fit. The PACE organization is responsible for performing the medical/functional assessment that determines if a person meets the Medicaid long-term care criteria. An interdisciplinary team, consisting of professional and paraprofessional staff, assesses the participants' needs, develops care plans and delivers all services, including acute care services, hospital services and if necessary nursing facility services.
PACE participants may disenroll from the program at any time and for any reason, and those with Medicare or Medicaid who disenroll will be assisted in returning to their former healthcare coverage. This flexibility allows people to try the program and switch if it doesn't meet their needs.
Comprehensive Services and Benefits
PACE covers all Medicare Parts A, B and D benefits, all Medicaid-covered benefits, and any other services or supports that are medically necessary to maintain or improve the health status of PACE program participants. This broad coverage eliminates the gaps that often exist between separate healthcare plans.
The range of services available through PACE is extensive. At the PACE center, participants receive primary care, therapy, meals, recreation, socialization and personal care; in the home, PACE offers skilled care, personal care supportive services, and supports such as ramps, grab bars, and other tools that facilitate participant safety; and in the community, PACE offers access to specialists and other providers.
| Service Category | Examples |
|---|---|
| Medical Care | Primary care including doctor and nursing services, medical specialty services, hospital care, emergency services |
| Therapy and Rehabilitation | Physical therapy, occupational therapy, recreational therapy |
| Medications | PACE provides all medically necessary medications without co-payments |
| Home and Community Support | Home care, adult day care, meals, nutritional counseling, social services |
| Specialized Services | Dentistry, laboratory/x-ray services, nursing home care as needed |
| Transportation | Safe door-to-door travel between home and the PACE center, as well as other health care appointments |
How PACE Differs From Traditional Medicare
The PACE program becomes the sole source of Medicaid and Medicare benefits for PACE participants, and financing for the program is capped, which allows providers to deliver all services participants need rather than limit them to those reimbursable under Medicare and Medicaid fee-for-service plans. This integrated approach means participants don't juggle multiple insurance plans or worry about whether a service is covered by Medicare but not Medicaid, or vice versa.
Once enrolled, PACE replaces traditional Medicare coverage for participants. If you are enrolled in the PACE plan, all the services normally provided through Medicare and Medicaid are administered through the PACE plan. It's essential to understand that joining PACE means stepping away from a Medicare Advantage plan or other supplemental coverage and allowing PACE to manage all your care coordination.
The Interdisciplinary Care Team
A team of healthcare professionals—experienced in working with older adults—develops and coordinates a personalized plan of care for each participant, and this team collaborates closely with the participant and their family to ensure needs are met effectively. The team includes doctors, nurses, therapists, social workers, and other specialists who communicate regularly to adjust care as health changes.
A team of professionals assesses and meets the health needs of each person in the program from primary care, social work, and physical and occupational therapy, to home care, dietary support, and more. Having a single team means fewer missed communication gaps and a more cohesive approach to managing complex health needs.
The Enrollment and Ongoing Care Process
Enrollment in PACE begins with assessment. The PACE organization's Interdisciplinary Team completes a comprehensive needs assessment. During this evaluation, the team determines your health status, functional abilities, social support, home environment, and what services would best help you remain safely in the community.
If an individual elects PACE, an Enrollment Agreement is signed that contains the participant's demographic data, description of benefits, effective date, explanation of policy regarding premiums, emergency care protocol, and rights and responsibilities. Once you're enrolled, your care plan is regularly reviewed and updated to reflect changes in your condition or needs.
PACE enrollment will continue until the participant's death regardless of changes in health status. This stability is important for seniors who face uncertain health trajectories; the program adapts as they change rather than forcing disenrollment due to increased care needs.
Special Considerations for Dementia Care 📋
PACE has proven especially beneficial for persons with Alzheimer's disease and related dementias, and according to the National PACE Association, almost 50% of program participants have a diagnosis of dementia. The structured daily activities, social engagement, and coordinated medical and behavioral health support at PACE centers provide meaningful benefits for people with cognitive decline.
For family caregivers of people with dementia, PACE offers additional support. PACE includes respite care and caregiver education. Respite care gives primary caregivers a break by having the PACE center or in-home staff provide care temporarily, while education helps family members understand the condition and manage it more effectively.
Practical Takeaways About PACE 💡
- 📍 Geographic availability matters: PACE is not available everywhere. Check whether your area has an operating PACE program before considering enrollment.
- 🏥 All-inclusive coverage: PACE combines Medicare and Medicaid benefits into one plan, eliminating gaps and reducing the need to coordinate multiple insurers.
- 👥 One care team: Instead of multiple doctors and specialists, you work with a coordinated interdisciplinary team that communicates regularly.
- 🏠 Aging in place: PACE is designed to help seniors remain in their homes rather than moving to nursing facilities, which many people prefer.
- ⏰ 24/7 support: PACE organizations provide round-the-clock services, meaning help is available whenever you need it.
- ✋ Easy exit: You can disenroll from PACE at any time without penalty, making it low-risk to try the program.
Finding and Joining a PACE Program
The first step is to determine whether PACE operates in your area. There are PACE programs serving participants in multiple states and the District of Columbia. You can search for nearby PACE organizations by contacting your state's Medicaid office or using online directories maintained by state health agencies or the National PACE Association.
Once you've identified a local PACE organization, a PACE organization will help potentially eligible seniors apply for Medicaid and with initial asset and income evaluation, and will also help prospective participants obtain the required financial information and verification documents. The PACE team handles much of the paperwork and assessment process to make enrollment as smooth as possible.
If you are considering long-term care options and aging in place is important to you, talking with a qualified healthcare professional about whether PACE fits your situation, health needs, and location can help guide your next steps. The program offers a structured, comprehensive approach to managing the medical and social aspects of aging that many seniors and their families find valuable.