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.

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.3 Living alone is a major risk for nursing home placement.4


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.5

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 2.6.6 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 7



  • 27% of dually-eligible beneficiaries 65 years of age and older had a hospital admission (2007)8
  • 19% of all Medicare beneficiaries had an annual hospital admission (2015)9

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.10

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.11

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.”12

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.”13

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.


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  2. PACE programs.
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  10. Division of Health Care Finance and Policy, Executive Office of Elder Affairs. (2005). PACE Evaluation Summary.
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