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PACE Preserves Independence at Home
By Randy Hebert, MD


The Program of All-Inclusive Care for the Elderly (PACE) is a model of care focused on maintaining the ability of our most vulnerable citizens to live in the community. The model is founded on the belief that the well-being and dignity of seniors with chronic illness is maximized by preserving independence in their homes for as long as possible.

To qualify for PACE, a person must be age 55 or over and be certified by the state as needing nursing home level of care. The typical participant is 80 years old, has eight chronic medical conditions, and limitations in three activities of daily living. In addition, most are low income and enrolled in both Medicare and Medicaid (i.e. dual eligible). Nearly half have been diagnosed with dementia. Nonetheless, despite these high care needs, 90 percent of participants are able to live in the community.

PACE can successfully provide care because the care team focuses on a small number of people (e.g. a national average of approximately 110 participants per medical provider) while using the expertise of a multidisciplinary team to anticipate and address the continuum of participants physical, psychosocial, spiritual, and practical needs.

Services include:

Health and Wellness Center: PACE programs are often centralized in a center that houses a medical suite, pharmacy, day center, a dining area, showers for participants, and laundry facilities.

Medical Care: is coordinated by a primary care provider with expertise in the care of the frail elderly, with the support of nursing, physical and occupational therapy, home health care, hospice, audiology, dentistry, optometry, podiatry, and specialist services as needed.

Social services: key members of the interdisciplinary team include social workers, transportation staff who drive participants to the center and medical appointments, day center staff, clergy, recreational therapists, and music therapists.

These services come together in a “typical day” for a participant who will be picked up at home by a PACE van and driven to the day center. When at the center, the participant will have meals and laundry provided as needed. They will spend some time socializing with other participants, may see physical and occupational therapy who will assess and develop a plan to maximize their ability to live safely in the community, and see the medical providers and other team members as needed and on a scheduled basis. When not in the center, participants will be called and/or seen at home by staff. This model of care is associated with fewer hospitalizations, readmissions, and nursing home placements at
lower costs than seen in comparable patient populations. Finally, the PACE model has certainly not been immune from the effects of COVID-19. Our day centers, therapy gyms, and dining areas are operating at much less than full capacity. As a result, all team members are doing more home visits and are newly using telehealth technology to care for participants. However, our mission is unchanged—to provide the full continuum of care necessary to allow participants to enjoy their lives to the fullest.

Dr. Randy Hebert is Medical Director at Community Life. For more information, call (866) 419-1693 or visit commlife.org.



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