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.


  1. Core Differences Between PACE and SNPs, National PACE Association Online Fact Sheet Source
  2. October 16, 2018 interview with Mary Ellen Dugan, Chief Operating Officer, Element Care.
  3. Program of All Inclusive Care for the Elderly Study, Commonwealth of Massachusetts, May 4, 2015, Mercer. Source
  4. Ibid.
  5. Ibid.
  6. Ibid.
  7. October 16, 2018 interview with Mary Ellen Dugan, Chief Operating Officer, Element Care.
  8. October 17 interview with Gregory Wilmont, Assistant Vice President, Neighborhood PACE.
  9. October 16, 2018 interview with Mary Ellen Dugan, Chief Operating Officer, Element Care.
0 replies

Leave a Reply

Want to join the discussion?
Feel free to contribute!

Leave a Reply

Your email address will not be published. Required fields are marked *