The Facts About PACE in Massachusetts


  • All PACE enrollees meet the state’s definition of nursing home eligible
  • PACE enrollees are frail, with significant functional and chronic conditions
  • PACE enrollees are largely dually eligible, which means that they have coverage under the Medicare and Medicaid programs
  • PACE enrollees have many behavioral health conditions and many social determinant of health (SDOH) needs, including food, housing, social supports, and companionship to reduce loneliness and isolation


  • PACE enrollees have choice on many levels
  • PACE enrollees have choice over what they receive and how they receive services and supports from the PACE program
  • PACE provides care and services to enrollees in the community
  • PACE supports enrollees in what they would like to do every single day: older adults have the option to remain at home, go out into the community, or come to the PACE Center for a few days a week or not at all


  • PACE enrollees are satisfied
  • Very few PACE enrollees dis-enroll from the PACE program


  • Integration occurs on many levels: at the system level, at the program level, and on the individual level
  • Integration occurs between Medicare and Medicaid Services
  • Integration occurs through the Interdisciplinary Team
  • Integration “in action” takes place through the enrollee care plan


  • Every PACE enrollee has a holistic and comprehensive care plan
  • The enrollee’s care plan incorporates and addresses all needs ranging from medical to behavioral health to long-term services and supports to important social determinant of health (SDOH) needs such as food, transportation, and housing
  • PACE keeps people out of nursing homes, hospitals and away from the emergency department by emphasizing wellness and prevention and providing an array of services to address the care needs of this frail population
  • Only 13 percent of PACE enrollees reside in a nursing home out of the 100 percent that are eligible for a nursing home


  • PACE makes sure that every enrollee has an end of life plan
  • An end of life plan is critically important to PACE enrollees and ensures that an individual’s preferences are known before a health crisis


  • PACE operates like an emergency response team in the community, responding to the needs of every enrollee during a state of emergency


  • PACE is fully capitated, assuming 100 percent risk for any costs exceeding the monthly fee paid by Medicare and Medicaid
  • The PACE program costs less to the government than the fee-for-service equivalent (FFSE), as determined by the federal and state government


Candace Kuebel, Executive Director, MassPACE Association
40 Court Street, 10th Floor,
Boston, MA 02108

To download and/or print this fact sheet, click here.



Issue Brief #1: Integrated, Holistic Care for PACE Enrollees

The Massachusetts PACE program includes eight PACE programs serving over 5,000 enrollees. Over 70 percent of current PACE enrollees have been in the PACE program for more than 2 years, evidence of the high satisfaction among PACE enrollees with their PACE program choice. The average age of a PACE enrollee is 77 years old, while 70 percent of enrollees are women.

PACE in Massachusetts: The Original Innovator of Integrating Medicare and Medicaid Services.

At its start in 1988 as a Program for All-Inclusive Care for the Elderly (PACE) demonstration site, the Massachusetts PACE program was developed as a site-based, provider-sponsored program with full integration of all Medicare and Medicaid services. PACE brings together both care delivery and financing through a capitated payment in one program. PACE provides comprehensive medical, behavioral health and long-term services in addition to social supports to adults age 55 and older who are nursing home eligible and want to live in their local communities.1 Integrated care and services provided through PACE programs in Massachusetts leads to participant satisfaction, sense of well-being and quality of life. Most PACE participants in the state stay with the PACE program for many years; few disenroll from the program.2

This issue brief highlights PACE approaches as the original innovator of integrating Medicare and Medicaid services to support community-based living for the frailest, often chronically ill individuals through site-based and field-based care in their communities and homes. This brief also notes the program’s integrated financing through capitated payment is structured to support integrated, efficient provision of care and supports to individuals when they need them.

Integrated Care at One Site Provided by One Team

PACE is more than coordinated care. The PACE program delivers full integration of all services by a team of providers integrated into the PACE center in a family-like atmosphere. PACE providers have strong relationships with their members and serve as an anchor for care and support. Most PACE providers have developed specialty services for podiatry, vision, and dental services that are located on-site with regularly scheduled visits by providers.3 Integrating providers into the site removes practical barriers like transportation, time and physical limitations that make going to multiple places for services difficult and complicated for frail and elderly individuals.


Transportation is a required and important PACE service. Drivers are an extension of the interdisciplinary team (IDT) and greet individuals first thing in the morning and bring them home at the end of the day. They are the eyes on the person and often are the first to see and report changes in condition to PACE enrollees’ care team.

Each PACE center must establish an interdisciplinary (IDT) team to comprehensively assess and meet the individual needs of each person. At a minimum, an individual’s team includes 11 positions. The team is shown on the following list.

The PACE Interdisciplinary Team (IDT)

  • Primary care physician
  • Registered nurse
  • Master’s level social worker
  • Physical therapist
  • Occupational therapist
  • Recreational therapist or activity coordinator
  • Dietitian
  • PACE center manager
  • Home care coordinator
  • Personal care attendant
  • Driver or representative4

Daily IDT team meetings are a pillar of PACE care integration. There are daily discussions of any issues that may have occurred the night before or previous day that need action to keep their PACE participants well and stable in their communities. MassHealth’s PACE program study conducted by Mercer Government Consulting in 2015 found that daily meetings demonstrate the PACE IDT team’s ability to quickly identify issues and provide immediate intervention. The study highlighted the team’s deep understanding of participants’ health conditions, home issues, living situations, preferences, and personalities. The same providers are responsible for assessing care needs, developing and updating care plans, providing care and coordinating care for program participants.5

PACE IDT teams have both primary care practitioners, and on-site dedicated behavioral health (BH) practitioners. They work together to address PACE participants’ medical and BH needs which is reflected in each person’s integrated care plan that addresses all service and support needs.6

Because care delivery is integrated, PACE can meet the needs of enrollees in a holistic manner. PACE addresses the needs, supports and social risk factors of PACE enrollees. These social risk factors are also most commonly known as the social determinants of health (SDOH). PACE staff help enrollees to secure nonmedical supports essential to their health and well-being such as housing and food. PACE enrollees get light snacks and a meal every day, exercise, interact with peers, and bond with PACE center staff.

Staff help identify appropriate housing options, accompany members to housing courts and legal services, help with food stamp applications, work closely with protective service agencies and address very personal issues, such as getting rid of bed bugs with center services (e.g. placing personal belongings in a box and laundering onsite).7

Integrated Care Connected to and in the Community

PACE provides integrated care and supports in peoples’ homes and communities. PACE connects with family and caregivers in the home, and functions as their surrogate family when they are alone. PACE personal care attendants (PCAs) and nurses support PACE enrollees’ daily living needs by assisting with bathing, dressing, meal preparation, and other essential supports for community living. Staff observe and address risks in the individual’s home and community surroundings. Examples include: looking for rugs they may trip on, identifying needs for durable medical equipment (DME) such as grab bars in the bathroom, addressing clutter and cleanliness, ensuring that there is food in the kitchen for enrollees, and pets that need to be fed. They track an individual’s stability and act on information shared during daily IDT meetings to put additional/different services needed in the home.

PACE providers have protocols in place at hospital emergency departments to mobilize staff to help with services needed and discharge planning if the person were admitted to the hospital. The East Boston Neighborhood PACE is on the same electronic health record (EHR) system, Epic, with their local hospitals which sends an alert to the center that a PACE participant entered the emergency department or was admitted to the hospital. The program has an onsite hospital-based nurse who spends 90 percent of her time working with individuals in the emergency department and conducts in-person discharge planning to make sure services and follow-up appointment are in place to keep individuals stable at home and avoid hospital readmission.8

Proactively addressing and integrating service needs when hazardous weather is predicted and mobilizing IDTs during emergency situations is essential to keeping PACE participants safe in their communities. When a snow storm is predicted, staff go out to meet participants where they live to provide services so that they do not have to travel to the PACE center when there are dangerous road conditions. Element Care received word that one of its participants in Lynn lived in a building that suffered a devastating fire. Staff went out to canvas the community and found the displaced individual and placed her in temporary housing. During and after the September 28, 2018 gas explosions in Merrimack Valley, Element Care mobilized its IDT team to put immediate short term and longer-term plans in place to find their participants and keep them safe and placed in appropriate shelter and housing. 9


Element Care’s IDT team went into immediate action to respond to the Merrimack Valley gas explosions to ensure its PACE enrollees and workers were safe and had shelter, medication and other care and supports needed. Within 15 minutes of the 4:45 pm explosions and resulting fires, the center’s nursing staff, on-call communications and operations staff were in communication and began identifying PACE enrollees and workers in impacted communities. Within three hours, calls were made to enrollees and messages left to contact Element Care’s on-call hotline and to take medications with them if evacuated. Element Care convened a Command Team, holding a conference call by 8:00 pm during which they identified 63 enrollees affected, most in the Mary Immaculate assisted living facility or skilled nursing facility.

The whereabouts of 19 enrollees was unknown. Calls and messages to enrollees continued, as well as efforts to identify and reach out to the 18 workers residing in Merrimack Valley. The next day, they closed the Nevins site to enrollees and kept it open to staff. Nursing staff scheduled visits for enrollees in need of services due to site closure. By 10:30 am, the day after the explosion, Element Care was in direct contact with all but one enrollee who was affected by the explosion. They were able to confirm with that individual’s landlord that they had been picked up by a friend. Personal care attendants (PCAs) were sent out into the community to provide supplies, medication planners and other supports. Planning then turned to weekend preparations, since gas and power had not been restored in the area. Element Care had its Transcare driver on-call for the needed participant rides and three other drivers volunteered, if needed. Social workers reached out to skilled nursing facilities for available beds in Merrimack Valley.

Temporary placements were made for individuals in need. By Monday, September 17, 2018, all community PACE enrollees were reported as safe. Over the next weeks, Element Care tracked which members remained without restored gas and which had received hotplates and space heaters. Element Care provided services and supports – such as, nursing visits, PCA visits and showers at the center. The Center assessed its response to the explosions by soliciting feedback from the team on positive and negative lessons learned for future emergency planning and response efforts.
Source: Element Care.


Rashpal is a 74-year old PACE enrollee. This is a story about her life. She is a Hindi-speaking woman with severe, untreated Post-Traumatic Stress Disorder (PTSD) and many health issues including diabetes and heart disease with a history of strokes. She was born in Punjab, India in a lower middle-class family. Her father died when she was a baby. Her mother raised Rashpal and her four older siblings.
When India was partitioned, creating millions of refugees overnight, Rashpal and her family found themselves in a foreign country, where they were not wanted. Pogroms and lynchings began almost immediately as Hindu homes were attacked and pillaged by mobs. As a young child, Rashpal came to witness acts of violence and mayhem that would have a long-lasting impact on her. Gathering what few belongings they could, the family fled toward the border under the cover of the night. They were among millions of refugees that had poured into India from Pakistan. Having lost all their possessions, they were living in dire poverty.
Eventually a marriage was arranged for Rashpal, and she moved to a small farm. Hunger and disease followed her there too. Rashpal bore many children; three of them survived. Rashpal always had fragile health – and, as she grew older, her health deteriorated further. Mental health issues compounded her problems. In India, Rashpal had no resources to seek health care.
Once in the United States, her fear of government officials and authority figures, stemming from untreated childhood trauma, stopped her from getting medical care. When Rashpal first met our staff, she would not allow anyone to come closer than about six to eight feet. Her anxiety and fear were overwhelming. She could only withstand a short contact with the providers. Very slowly, we talked to Rashpal about her experiences. We met her at home, in the center, in presence of her children and then eventually, alone.
Our PACE Social Worker recorded her memories in his notes, which are included in her chart. Her experiences would have deeply affected anyone who had the misfortune to live through something like it. Through patience and sharing, through speaking Hindi and relating to her fears, our relationship was established. Our PACE Social Worker knew a great deal of Indian history and was able to relate to the events that Rashpal was describing. This knowledge melted her resolve. Our staff takes her to specialist appointments. The driver “collects” her in her apartment, accompanies her to the visit, brings her back and helps her settle in her apartment. We are not “curbside drop off.”
Today, PACE is able to meet Rashpal’s needs. It has been a long journey. Rashpal trusts us enough to allow physical exams, phlebotomy and an Electrocardiography (EKG). She allows us to accompany her and to help her with showering and personal care. Her dentures were made for her and she can now eat solid food which our Aides help her to prepare. Rashpal has finally been able to reclaim her dignity.
Source: Serenity Care.

PACE Financing Supports High Quality and Efficient Integrated Care and Supports

PACE care integration is supported by its fully integrated Medicare-Medicaid financing structure under a capitated model of payment. Savings achieved on acute care are reinvested in behavioral health, LTSS and SDOH services. Capitated payment builds in flexibility to provide services that best meet PACE participants’ needs. The program is incentivized to meet participants’ needs in a holistic approach that results in integrated care supporting individual’s well-being and goals for community living.

Looking Ahead

The Massachusetts PACE program is nearly 20 years old. It is a powerful program as a model for integration.
PACE is the first truly integrated program of its kind operating alongside the big health plans and provider systems. The PACE program continues to enable frail enrollees to remain in the community and plans to do so for many years to come.

To download and/or print this issue brief, click here.


Issue Brief #2: More Appropriate Care for PACE Enrollees

The Massachusetts PACE Program: A Leader in Reducing Nursing Home and Hospital Use.

The PACE program is responsible for over 5,000 older adults who all meet the state’s nursing home eligibility standards; however, only 13 percent of the enrolled population lives in a nursing facility. PACE supports their right to live in the community.

PACE enrollees are at high risk for nursing home stays, hospitalizations, and emergency department visits. Older adults who enroll in the PACE program must meet the state’s eligibility for nursing home level of care. This means that PACE enrollees are frail with significant functional needs, and a range of chronic conditions and disabilities that qualify them for nursing home care. Still, the Massachusetts PACE program is a leader in keeping PACE enrollees out of nursing homes and hospitals. The PACE program is an effective model in providing more appropriate care to enrollees to address their needs at home and in the community. The PACE model is not just good for payers. It is especially good for PACE enrollees who often face setbacks in making the transition back to the community.1

This issue brief provides overall evidence on the effectiveness of the overall PACE program in Massachusetts in preventing expensive nursing home stays, hospital admissions and emergency department visits for its PACE enrollees. This brief also brings attention to the performance of the PACE model, as examined by the MassHealth program and nationally.

The PACE Population: Frail, Older Adults with High Needs


The graph below provides a simple profile of the PACE population in Massachusetts. Older adults enrolled in PACE are at greater risk of nursing home and hospital use, because of their nursing home eligibility status, dual-eligible status and income status, behavioral health conditions and needs, living arrangements such as living alone, and age.

In Massachusetts, eight PACE programs operating under contract with the MassHealth program and the federal government provide comprehensive and integrated care to nearly 5,000 PACE enrollees, for whom receiving appropriate care in an integrated and holistic manner is critical.

As the graph shows, 100 percent of PACE enrollees are certified as nursing home eligible by the state, or the MassHealth program.2

Close to 95 percent of PACE enrollees are dually eligible, which means that they have been defined by federal and state governments as one of the most vulnerable populations covered under the Medicare and Medicaid programs. Those who have both coverage types are called dually eligible.3

Many PACE enrollees have significant behavioral health needs: 66 percent of all PACE enrollees have a behavioral health condition; however, some programs report as high as 90 percent. Over half of PACE enrollees living in the community live alone. Finally, the PACE population in Massachusetts is largely 65 years of age and older. Close to 90 percent of PACE enrollees are 65 years of age and older, while 32 percent of all PACE enrollees are 85 years of age and older.

The PACE model supports the development of strong relationships among staff and between staff and enrollees. Staff know each other well, and they know their enrollees. Visits to the PACE Center, and visits to their homes provide staff with opportunity to keep track of the factors that place enrollees at risk of a nursing home admission or hospital admission or emergency department visits. Staff closely monitor the social determinants of health including mental health needs, isolation, and housing stability. Housing instability is one of the biggest challenges facing older adults.4 Living alone is a major risk for nursing home placement.5


The Record on PACE: Delaying and Preventing Nursing Home and Hospital Admissions

As the U.S. Department of Health and Human Services remarked in a comprehensive review of PACE evaluations across time and states, there are no perfect comparisons to be made between the PACE programs and other programs.6

PACE enrollees are in a category of their own, as the entire enrollment pool is at risk of nursing home admission, at risk of hospital admissions, and at risk of emergency department visits.

PACE programs focus on ways to prevent the use of high-cost services – and the challenging transitions that follow them – by providing services in an integrated and holistic manner, preventing illness, and addressing the SDOH factors that often drive outcomes.

That said, the PACE population is often compared to populations including: (1) the dually-eligible population at large, and (2) the Medicare population. Along the continuum of risk, however, PACE enrollees face greater risk than these comparison populations. One way to understand what risk means in this context is to compare the relative risk of enrollees in PACE to the average risk of the Medicare population.

Assume, for example, that the average risk of the Medicare population is 1.0, the average risk score for the PACE population is closer to 2.6.7 This means that the PACE population is 2.5 times more frail than the average Medicare beneficiary.

For this issue brief, the PACE programs provided data on the number of PACE enrollees that reside in a nursing facility, as well as the number of PACE enrollees that had hospital admissions. The experience of PACE enrollees was very positive relative to the comparison populations.

A Comparison Between the Overall PACE Program and Other Populations Nursing Home Use and Hospital Admissions


Comparison Population Had:




  • 22% of dually-eligible beneficiaries 65 years of age and older resided in an institution receiving services through the fee-for-service system (2007)
  • 17% of dually-eligible beneficiaries of all ages 8 9



  • 27% of dually-eligible beneficiaries 65 years of age and older had a hospital admission (2007)10
  • 19% of all Medicare beneficiaries had an annual hospital admission (2015)11

Massachusetts: Three Studies Supporting the Effectiveness of the PACE Program

Over the last 10-15 years, the state has undertaken three key studies, which have all supported the effectiveness of the PACE program.

In the first study, conducted by the Division of Health Care Finance and Policy (DHCFP) in 2005, the state found that PACE program keeps enrollees well and out of a hospital. PACE was compared to a group of older adults who, like PACE program participants, were nursing home eligible, but receiving care in a home or community rather than institutional setting, and a sample of nursing home residents. The analysis found that PACE inpatient days, average length of stay, and outpatient emergency department visit rates were lower than the nursing home group. PACE also showed lower rates of inpatient discharges, days, and emergency department visits than the waiver group.12

In the second study, conducted by JEN Associates, Inc. in 2015, the state’s consultant found that the PACE program was effective in reducing nursing facility residency. The study found that the average episode length is 20% shorter for PACE enrollees than for controls, 14.8 vs 18.5 months.13

In the third study, conducted by Mercer Government Consulting in 2015, the state’s actuaries found that the “PACE plans are utilizing resources very differently than the actuarially equivalent population enrolled in the FFS system. The HCBS/Home Health and LTC Facility services are significantly lower in the PACE program as compared to the FFS delivery model. The lower LTC facility costs are consistent with the PACE program goals of achieving a higher quality of life for their members while remaining in the community.”14

A National Review of the PACE Program

Understandably, the federal and state governments have conducted many reviews of the PACE program to determine the program’s effectiveness over the years. In 2014, the U.S. Department of Health and Human Services conducted a comprehensive review of existing evaluations of PACE. The report is called: “Evaluating PACE: A Review of the Literature.” In this report, the federal government offers several conclusions. One that is most relevant to this issue brief is this: “PACE enrollees have fewer inpatient hospitalizations than their FFS counterparts.”15

Looking Ahead

The Massachusetts PACE program is nearly 20 years old. It is a powerful program as a model for supporting choice, keeping seniors well at home and in the community, and out of the hospital and emergency department room.

PACE is the first truly integrated program of its kind operating alongside the big health plans and provider systems. The PACE program continues to enable frail enrollees to remain in the community and plans to do so for many years to come.


Candace Kuebel, Executive Director, MassPACE Association
40 Court Street, 10th Floor
Boston, MA 02108

To download and/or print this issue brief, click here.


Issue Brief #3: How PACE Programs Strengthened End-of-Life Planning and Care

End-of-life planning is a critical part of the services that persons nearing the end of life need, as is end of life care.

PACE programs respond to this need with their expertise, staff and systems in place to support families to undertake this very personal process in a way that empowers enrollees and helps to ensure they are cared for according to their wishes and treated with respect and dignity at the end of their lives. The PACE programs are set up to support access to high-quality end-of-life planning. Their small size, their attention to quality, and their fully integrated model of care remove barriers that prevent many seniors from receiving appropriate end-of-life planning.

This issue brief will discuss the key elements of end-of-life planning, as well as barriers to end-of-life planning happening; and finally, how PACE makes end-of-life planning and care a key component of its program by leveraging its integrated and personal model of care delivery.

PACE Programs Ease the Worry for Many Enrollees by Providing End-of-Life Planning

Through the PACE program, thousands of older adults who are nursing home eligible by the state’s standards receive end-of-life planning. As importantly, PACE Programs partner with participants and family members as care needs evolve through end of life.

PACE Programs are responsible for ensuring that over 80 percent of their enrollees have used the MOLST program for shared decision-making.

Key Elements of End-of-Life Planning and Care

End-of-life planning can encompass a wide variety of tools, processes and services that surround care and well-being in the final six months of life. Examples include the development of an advance directive or living will, use of the Medical Orders for Life-Sustaining Treatment (MOLST) program for shared decision-making at the end of life, and choosing a health care proxy or power of attorney.

Health care providers and families can use a variety of models to help guide patients through questions and decisions about their care before a crisis occurs to ensure that patients’ wishes are followed. The process includes many difficult questions such as whether to be resuscitated, whether to be put on a ventilator, whether to donate organs after death. That said, advance care planning improves quality of care at the end of life, including less in-hospital death and increased use of hospice.1 The planning process also increases patient and family satisfaction and reduces stress, anxiety, and depression in surviving relatives.2 The planning process generally addresses questions like:

Barriers to End-of-Life Planning

End-of-life planning would ideally be part of aging for most people, whether it is initiated by families, financial planners, or health care providers. However, it often emerges as a key unmet need when a person’s health is declining to the point that they require increasing support or a nursing-home level of care.

Only 35% of adults have put their end-of-life treatment wishes in writing, though 72% have thought about them and a majority have discussed them with someone else. Americans with higher incomes and levels of education are more likely to have documented their wishes.3 Public awareness of the tools and options for end-of-life planning is limited, so health care providers are often in the position of introducing these difficult questions.

Physician and national expert on the end of life, Atul Gawande, said recently that while reported rates of end-of-life wishes being honored in Massachusetts have increased from 58% in 2016 to 71% in 2018:

“I think it’s a bad sign for us in the medical profession that patients have so much better care when they have the conversation about what the wishes for their care turns out to be and yet, the majority of the time, the patients have to initiate the conversation. We’ve got a long way to go.”4

How providers initiate and support end-of-life planning—and provide the type of care that patients express preferences for—is critical to fulfilling end-of-life wishes. This includes ensuring that advance directives or other agreements on the type of care to be provided are communicated to, understood and followed by the care team; providing palliative care; and supporting patients and families through grief and the other challenges related to the death of a loved one.

Barriers to end-of-life planning can include lack of staff training or time to focus on these issues, care models that do not assign responsibility or establish processes to ensure that end-of-life wishes are documented and adhered to. These topics are often difficult for providers as well as patients and families to discuss during a stressful time; they also require communication by the care team to complete the planning process and make any adjustments as needed.

How PACE Programs Integrate End-of-Life Planning and Care

The PACE model integrates and promotes end-of-life care, centered around quality of life, and takes a holistic, personalized approach that is suited to providing these services effectively. PACE programs coordinate and provide all preventive, primary, acute and long-term care services so that individuals over age 55 can continue living in the community, rather than in a nursing home as they otherwise would need to. PACE programs reduce the fragmentation of health care services that often makes the end of life more difficult for patients and their families, using an interdisciplinary care team (IDT). The interdisciplinary care team approach integrates specialists in care for older people as well as social supports, in a more holistic model that fosters personalized care.

In Massachusetts, the average enrollment for PACE programs was 640 enrollees across the eight programs ranging from about 250 to about 1,500 enrollees. The typical PACE program is small, enabling personal relationships between enrollees, families and providers. PACE enrollees are able to live more independently, with 87 percent living in the community rather than in a nursing home. At the end of life, PACE enrollees are more likely to be able to die at home rather than in a health care facility, as most Americans would prefer to do.5

End-of-Life Planning in PACE and Care

PACE physicians are geriatricians trained to initiate end-of-life discussions with patients and families, and the personalized, holistic team-based PACE approach supports the planning process through the end of life. The PACE model includes comprehensive assessment upon enrollment, and the use of tools such as the MOLST to set priorities for end-of-life care from the outset. All patients receive information about end-of-life care during the PACE intake process, the initial assessment, the post-enrollment care conference with the care team, and at a family care conference that is offered when the patient becomes eligible for end-of-life care. PACE teams can use daily rounds and weekly team reviews of patients who are close to the end of life to ensure that planning conversations happen, and that the resulting information is documented and shared.

National PACE guidelines recommend that PACE organizations establish an End-of-Life Committee specifically to promote quality in end-of-life care in the organization. Participants’ care evolves naturally as health deteriorates and needs change. While statistics show that most Medicare beneficiaries who access hospice, do so for only a few days at end of life, PACE participants receive seamless palliative and end-of-life care by the same highly trained staff who know them and have cared for them, sometimes for many years.

Looking Ahead

The Massachusetts PACE program is nearly 20 years old. It is a powerful program as a model for end-of-life planning. PACE is the first truly integrated program of its kind operating alongside the big health plans and provider systems. The PACE program continues to enable frail enrollees to remain in the community and plans to do so for many years to come.


End-of-life planning is a key attribute of CHA’s holistic approach. CHA completes the MOLST and a Health Care Proxy (HCP) for over 80 percent of its enrollees, who have found comfort in conveying their wishes. Care and services are provided based upon the needs and choices of enrollees. CHA’s holistic approach for these two enrollees for whom CHA has completed a MOLST and a HCP is evident in the range of services that they receive to meet their total range of medical and non-medical needs.

CHA’s PACE enrollee with end-stage renal disease (ESRD) also has vascular dementia and persistent depressive disorder with melancholic features. CHA coordinates participant’s dialysis treatment, including rides three days a week using the PACE transportation-provided services. CHA provides in-home behavioral health, including medication management, and arranges for this enrollee to meet with nurse practitioner who specializes in psychiatric care every three months. CHA provides all appointments in the afternoon in one place, at the ESP Center, for this individual. This enrollee lives in supportive housing. CHA provides 24/7 access to Personal Care Attendant (PCA) services and medication reminders, along with personal care and housekeeping services, which includes laundry twice a month.

CHA’s PACE enrollee with metastatic major organ cancer requires enhanced end-of-life visits. This approach includes twice weekly visits from a Registered Nurse and once weekly visits from a Social Worker and an Occupational Therapist. CHA arranges for weekly visits by a contracted end-of-life chaplain, and weekly visits from a contracted end-of-life registered nurse. This enrollee lives in an assisted living facility, and ESP contracts for the standard services of an assisted living facility, which includes 60 minutes daily support for activities of daily living (ADLs), meals, housekeeping, pharmacy reminders, and a range of other activities.

To download and/or print this issue brief, click here.