Review
Program of All-Inclusive Care (PACE): Past, Present, and Future

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From modest beginnings in 1973 to over 60 programs nationwide, the PACE concept has proven the value of integrated, interdisciplinary-based care for frail older adults. The evolution of PACE and its regulatory and reimbursement model have changed over time, but the principals of care have remained unchanged. Nationally PACE programs are dealing with some of the same challenges they had 30 years ago and yet PACE programs continue to expand and provide care to an ever wider distribution of populations. The looming issue of ever-growing health care expenditures represents another opportunity for PACE to demonstrate its value while providing a level of quality beyond what could normally be provided by typical Medicare and Medicaid payments for similar conditions and patient characteristics. The future for PACE includes a number of possibilities including flexibility in financing and reimbursement, design changes to work with community-based physicians, potential eligibility adjustments, and growth of rural PACE. The PACE model has clearly demonstrated that in a debilitated, frail population in whom health care expenses would be expect to be high, a combination of team care, managed health care services, and care coordination can lead to both improved health outcomes and reduced expenses over time.

Section snippets

Background and History

PACE programs are comprehensive community-based care models for frail, chronically ill older adults whose significant functional and cognitive impairments make them nursing home eligible. The first PACE program had an auspicious start in the Chinatown section of San Francisco in 1971. Based on consultant work by Marie-Louise Ansak and a $2000 federal grant, On-Lok was founded.4 The vision of the program was to develop an alternative to nursing home care in the Chinese community, where

PACE Programs

The population served by PACE includes impaired and frail elders who, while living at home, are nursing home eligible and likely to require on-going care. According to the National PACE Association, the philosophy of the PACE model is centered around the belief that it is better for the well-being of seniors with chronic care needs and their families to be served in the community whenever possible. Practice innovations in PACE include the use of an interdisciplinary team, consisting of many

Outcomes

In general, PACE programs improve the quality of care and access to services based on need. Significant outcomes that are across all PACE programs include greater adult day health care use, lower skilled home health visits, fewer hospitalizations, fewer nursing home admissions, higher contact with primary care, longer survival rates, an increased number of days in the community, better health, better quality of life, greater satisfaction with overall care arrangements, and better functional

Why Is PACE So Hard To Do?

Thirty-five years after the humble beginnings of On Lok, the model still struggles with efforts to serve more of the nursing home–certifiable population nationally. Many have asked, why aren't there more PACE programs serving more elderly? Why is the model not in every state? Why aren't providers flocking to the table to pursue the concept?

There is no one answer to these questions but rather a host of reasons that vary dramatically by state and even the actual location of the PACE program. One

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