PACE Providers Shift Services Toward the Home Amid Nation’s Long-Term Care Overhaul

This was originally posted on Read the full article here.

The COVID-19 pandemic has revealed a dire need to rethink how and where Americans age, most long-term care experts agree.

Investing in small-home senior living and “nursing homes without walls” are among the several innovative ideas that have been floated over the past year. Alternatively, some aging services stakeholders have simply called for a sweeping redirection of government funds away from facilities toward in-home care, something President Joe Biden is backing in his newly proposed “American Jobs Plan.”

There’s another way to reimagine long-term care in the U.S. that isn’t being talked about nearly enough, however: Programs of All-Inclusive Care for Elderly (PACE).

“I think we’re now in a situation across the country, as well as in Massachusetts, where PACE is being recognized as a significantly improved opportunity and alternative for health care delivery,” Dr. Rob Schreiber, vice president and medical director of Fallon Health’s Summit ElderCare, told Home Health Care News. “Specifically for those who are nursing home eligible and want to maintain their lives in the community.”

As of March 30, there were at least 138 PACE organizations operating 272 PACE centers in 30 states, serving roughly 55,000 participants combined, according to the National PACE Association.

Dr. Schreiber helps run Summit ElderCare, one of the largest programs of that bunch. Launched in 1995 as a subsidiary of the Worcester, Massachusetts-based health plan Fallon, Summit cares for nearly 1,200 PACE participants across five sites in the Bay State, plus one location in Buffalo, New York.

“PACE has been around for almost 50 years,” Schreiber said. “It’s still here, and it is one of the only validated models of care that has really been shown to improve quality, lower costs, improve quality of life and boost person-centered satisfaction. It checks all the boxes.”

Not every PACE operation is the same, but most work by melding center-based services with comprehensive in-home care. Summit, for example, coordinates services from social workers, nurses, rehab specialities and eight other disciplines.

“The key, the secret sauce to PACE is the interdisciplinary team,” Schreiber explained.


Read the full article here.


Focus on Lynn Seniors in New Vaccination Clinics

This was originally posted on Read the full article here.

LYNN — A new round of vaccinations will be going out to Lynn seniors next week, in the Commonwealth’s drive to get elderly people protected against COVID-19.

The new drive will be conducted by Element Care PACE, a Lynn-based elderly care organization that provides care to seniors who live independently, and will be focused on seniors that are in Element’s care.

“Our goal is to get the vaccine out as quickly as possible and as safely as possible, and to not waste any of it,” said Dr. Joanna Duby, the medical director at Element Care PACE.

The organization registered with the Massachusetts Department of Public Health (DPH), and received its first doses from the state this past Tuesday.

Element has already vaccinated its staff and will begin vaccinating hundreds of seniors at two clinics in Lynn next week.

Duby has found a strong interest in vaccinations among the population she works with.

“The seniors are the ones who want it more than a lot of younger people, because they’re the ones who have seen the devastating effects of the virus on them and their friends,” said Duby, who reported that approximately 180 of the 1,000 patients Element Care PACE works with had contracted the virus, and more than 50 patients had died.

“It’s been devastating. In addition to the risk of getting the virus, the social isolation has been awful,” she said. “They can’t eat with their friends, they can’t see their families, and it’s taken a huge toll on their mental health and their physical health.”

Duby said the process of getting the vaccinations set up was difficult, and that she wished seniors could have had access to the vaccines sooner.

“It’s been a challenge,” said Duby. “It’s hard to know when you’re getting a vaccine, how much you’re going to get, when you’re going to get it. We hoped that the rollout for seniors would be sooner, especially for places that have been hit hard like Lynn.”

As of February 1, residents 75 and older became eligible for the COVID-19 vaccine as the state opened the second phase of its vaccine distribution plan. However, that rollout has been blasted by state representatives and elderly organizations for being overly complex.

People 75 or older are asked to apply for a vaccination appointment through the state website, Duby reported that her organization was uniquely equipped to assist its seniors with navigating this process since its staff have close relationships with the individuals they care for and can provide them with vaccination information directly.

For other Lynn seniors, the process of getting registered has been more difficult.

Rosemie Leyre, 78, a Lynn resident, encountered several issues with the website when she tried to apply for a vaccination this week.

She found out about the vaccination process opening to seniors 75 and older from a neighbor, and went to the state website to apply. She entered her location and her zip code, as was requested by the site, she said.“It said this zip code does not exist,” she said. “Then I got a message that said ‘try again in 24 to 36 hours.’ And I had a few friends who had had the same experience.”

Eventually, she was able to apply through the “Patient Gateway” portal from Massachusetts General Hospital and scheduled an appointment for Wednesday evening at a Lynn site.

Leyre said her friends were very interested in getting the vaccine as soon as possible.

“The people I know are all very positive towards the vaccine,” she said.

Of the group of people she knows, she said only one of them was skeptical of the vaccination.

A Belgium native, Leyre hopes that once the virus subsides she will be able to visit her daughter, who still resides in her home country.

“I can’t believe how long it has been since I traveled,” she said.

Between A Quarter And A Third Of Health Care Workers Have Refused The COVID Vaccine

Read the full story here.

GBH featured CHA in a story about COVID-19 vaccination reluctance and efforts to promote its safety and efficacy. CHA PACE executive director Jed Geyerhahn and Avlot Quessa, senior director of multicultural affairs and patient services, discussed hesitancy on the part of CHA PACE staff and communities of color in general, and they highlighted CHA’s efforts to educate and support staff. CHA PACE nurse Yuly Mosca detailed her initial reluctance and ultimate decision to get vaccinated.


PACE program assists with care, transportation

To view and download a PDF version of this article, written by Melissa Erickson, click here.

Free program supports Massachusetts seniors living at home

This was originally posted on Read the full post and watch the video here.

COVID-19 has dramatically impacted older adults, through illness or the isolation often needed to keep them healthy. In Massachusetts, a free program is supporting those able to stay in their homes by partnering with families as the pandemic continues to take its toll.

Gloria Williams has always been independent. As she got older and her medical needs increased, she was determined to stay at her home in Dorchester.

“Just to leave my home and to a nursing home, I’m not ready for that yet,” Williams said.

So about 10 years ago, she joined MassPACE: Programs of All-inclusive Care for the Elderly. It’s a federally and state-funded program, an alternative to nursing home care that keeps seniors living at home.

“In general, older adults prefer to age in place at home if they can,” said Dr. Adam Burrows, medical director for the Upham’s Corner Health Center PACE program in Dorchester.

He said participants are 55 years and older, with medical and social needs that would qualify them for a nursing home. Instead, they’re trying to live at home and that’s where PACE teams come in.

“Made up of primary care providers, social workers, nurses, occupational and physical therapists, registered nurses, dietitians who together assess our participants, decide on a finely calibrated individualized care plans,” Burrows said.

Pre-COVID, much of this work had been done at the PACE centers — the clinical care as well social events — but the coronavirus changed that.

“So we relied on daily telephonic outreach. We relied on video technology. We relied upon staff going into homes,” Burrows said.

They also relied on family like Williams’ granddaughter, TaMarsha Williams. PACE hired and trained her to be Gloria’s personal care worker.

“It was all new to me, but I know I can give her the best care. When we were younger, she took care of me and my siblings and now it’s reversed. Me taking care of her, just trying to pay her back,” TaMarsha Williams said.

Burrows said that sense of community is exactly what PACE is about.

“When we think of taking care of these very vulnerable older adults, we’re also thinking about how do we create healthier households and healthier communities.”

There are 130 PACE programs across the country, eight of them in Massachusetts. Nationally, they’re seeing an increased interest in the program as families and older adults look for options.

MassPACE to Host Virtual Conference to Highlight Strategies for Improving Elder Care, Celebrate 30 Years of PACE

Massachusetts Secretary of Health and Human Services, Marylou Sudders, to join PACE Leaders and Frontline Workers in Speaking at Event


MassPACE, the Massachusetts Association of the Programs of All-inclusive Care for the Elderly (PACE), today announced it will host the second annual MassPACE Conference virtually from October 28-29, 2020. The event will bring together key elder care leaders and state and national partners to collaborate on improving care
for the vulnerable elderly population in the state of Massachusetts.

The 2020 event will feature presentations on how PACE has pivoted to an at-home care model to protect elderly participants during COVID-19; strategies to drive long- lasting change to elder care; and how to partner with health and community organizations to improve the lives of older adults. Attendees will hear from PACE leaders, frontline workers, and state representatives as they discuss the biggest issues facing elder care, such as evaluating nursing home placement, addressing health disparities, and preventing avoidable emergency department visits and hospitalizations for those most at risk.


Marylou Sudders, MSW, ACSW, the Secretary of Health and Human Services for the Commonwealth of Massachusetts, will deliver the welcome and keynote address. Since joining Governor Baker’s cabinet in January 2015, Sudders has led the Executive Office of Health and Human Services, which represents 52% of the state’s
budget, and is comprised of 12 agencies, 2 state-operated Soldiers’ Homes and MassHealth, the state’s office of Medicaid. Sudders has advanced strategic policy priorities, including restructuring MassHealth into a population-based health coverage system, addressing the opioid epidemic, integrating physical and behavioral health care, and strengthening community-based services. Governor Baker appointed Sudders to lead the Massachusetts COVID-19 Command Center, a role she continues to hold, in addition to serving as Health and Human Services Secretary.

Adam Burrows, M.D., Medical Director for Upham’s PACE, the PACE organization of Upham’s Corner Health Center, will speak to the session “Thinking About Nursing Home Placement,” elaborating on critical factors to consider while evaluating nursing home placement versus at-home care and highlighting the use of his organization’s hybrid consumer-directed personal care worker program as a strategy for caring for participants at home. Dr. Burrows has been the Medical Director of Upham’s PACE since its inception in 1996 and has helped guide the program’s expansion to three PACE Centers throughout the city of Boston. He is a member of the Boston University Medical Center’s Geriatric Medicine faculty and just completed a two-year term as Chair of the National PACE Association’s Board of Directors.

Robert Schreiber, M.D., Vice President and Medical Director of Fallon Health’s Summit ElderCare program, will present the session “A Proactive Approach to Early Identification of Risk During the Pandemic and Beyond,” focused on how to leverage data to identify and intervene with at-risk patients to prevent unnecessary hospitalizations. Dr. Schreiber oversees medical care for Fallon’s PACE program, which is the sixth largest in the country and largest in New England. With more than 1,200 participants, Fallon has 5 PACE sites in Massachusetts and one in Western New York. Previously, Schreiber served as Medical Director of Evidence-based Programs at Hebrew SeniorLife and Medical Director of the Healthy Living Center of Excellence.


Wednesday, October 28 – Thursday, October 29, 2020


The event will be held virtually. For more information, visit


To register for the event, visit

If you are a member of the media interested in complimentary access, please contact Kahler Buckley at

To learn more about MassPACE please visit Attendees looking to connect ahead of the conference can join the conversation on Twitter by using the hashtag #MassPACEConference2020.

Registration for the MassPACE Virtual Conference is Now Open!

Join with other PACE employees, vendors, elder stakeholders, and aging services providers as we celebrate 30 years of PACE in the Commonwealth of Massachusetts. PACE in MA has grown from one small pilot program in 1990, to eight programs serving almost 5,000 participants and their families and caregivers in 2020. And now more than ever, it is time to take this program statewide. We are positioned for exponential growth as we look to make this program more accessible, sustainable, and desirable for those who need it most – our valued older adults, and individuals with disabilities.

Challenges present opportunities. With the onset of the COVID-19 pandemic in March, 2020, the PACE model as well as related elder healthcare programs, have pivoted to turn Center-based care into home delivered care ranging from doctor house calls to social encounters and activities. For PACE, what changes have been made that could endure long after this pandemic subsides? How can we work together to achieve our vision of making PACE accessible to every eligible consumer in the Commonwealth? How can we better partner with other mission-driven elder health care and community organizations to continue to make the lives of our older adults better? Join us as our leaders, front line workers, and state and national partners present educational and networking sessions on these topics and more!

For registration, a list of this year’s speakers and an event schedule, visit our MassPACE Virtual Conference events page.

Event Details

Dates: October 28-29, 2020
Location: Virtual
Register here:

MassPACE Celebrates National PACE Month, Promotes Healthy Aging and At-Home Elder Care

BOSTON – September 9, 2020 – MassPACE, the Massachusetts association of the Programs of All-inclusive Care for the Elderly (PACE), is celebrating National PACE Month in September. The National PACE Association (NPA) has designated September as National PACE Month to raise awareness and celebrate the difference PACE makes in the lives of enrolled seniors, their families and their communities. PACE is a federally and state funded program that offers an alternative to nursing home care by providing eligible individuals with robust healthcare and social services to keep them living safely at home.

All of the PACE providers in Massachusetts are participating in National PACE Month by developing socially distanced programming to support older adults with long-term health needs and keep them engaged in their health. Element Care, a MassPACE program serving communities north of Boston and the Lowell and Lawrence regions, is conducting a Healthy Aging educational campaign to help members maintain their health while living at home. MassPACE is also using National PACE Month to highlight its ability to curb COVID-19 infections and, in many cases, fatalities. While 22 percent of infected nursing home residents in Massachusetts have died due to COVID-19 infection according to Dignity Alliance Massachusetts, less than 2 percent of MassPACE participants residing at home have succumbed to the virus.

“Every September, National PACE Month affords us a wonderful opportunity to highlight the significant impact our program has on elders as well as their families and communities,” said Candace Kuebel, executive director of MassPACE. “Though this year is different because of COVID-19, we are celebrating the resilience of our program and our ability to pivot and continue helping seniors living at home while navigating social distancing protocols. It has been a challenging several months, but we are happy that our unique structure has allowed us to continue upholding our mission of giving our participants freedom to live their lives in the community.”

To adapt to the pandemic, MassPACE member agencies swiftly transformed their care model, previously based in physical PACE centers, to at-home care delivery. The programs deployed tablets and similar technology for audio and video telehealth, social programming, nutritional counseling, and more to prevent gaps in care and sustain member engagement throughout the pandemic. The programs have also provided additional support and training for family caregivers when they are available to care for loved ones. Clinics at MassPACE centers have remained open by appointment, even while many appointments took place in participant homes.

“Caring for older individuals with multiple healthcare needs has been particularly challenging during this pandemic,” said Shawn Bloom, NPA president and CEO. “To keep participants and staff as safe as possible, the PACE model of care has been adapted from bringing individuals into a PACE center several times a week to providing services in the home. The flexibility of the model in the face of this pandemic has been inspiring.”

Massachusetts was one of the first states to pilot PACE. Since the launch of its first program in 1990, the Massachusetts PACE programs have grown to be one of the largest in the nation, serving more than 5,000 elderly individuals through eight regional programs across 28 PACE centers. Nationally, a total of 134 organizations operate 264 PACE centers in 31 states. Currently, more than 51,000 individuals are enrolled in the program. Though all enrollees are eligible for nursing home care, PACE has been successful in keeping more than 95 percent of its enrollees in the community and out of nursing homes.

In order to enroll in PACE, a person must be 55 or over, live in the service area of the PACE organization, meet clinical eligibility requirements for nursing home placement, and be able to live safely in the community with the support of the PACE organization. To learn more about MassPACE and enrollment, please visit

About MassPACE

The MassPACE Association’s Mission is, through advocacy, education and policy research, to provide leadership and support for growth, access, quality, and success of PACE in the Commonwealth of Massachusetts. The VISION of MassPACE is that PACE will be accessible to every eligible consumer in the Commonwealth of MA and recognized as an extraordinarily innovative, accessible, valuable and effective model of care for individuals with significant healthcare needs.

About The National PACE Association

The National PACE Association (NPA) works to advance the efforts of PACE programs, which coordinate and provide preventive, primary, acute and long-term care services so older individuals can continue living in the community. The PACE model of care is centered on 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. For more information, visit and follow @TweetNPA.

Media Contacts

Ashley Owen for MassPACE
(978) 257-9000
Robert Greenwood for National PACE Association
(703) 535-1522

Webinar: Caring for Older Adults with Complex Needs in the COVID-19 Pandemic: Lessons from PACE Innovations

Date and Time: June 30, 2020, 2:00 – 3:30 pm ET (11:00 am – 12:30 pm PT)
Register Here

The Program of All-Inclusive Care for the Elderly (PACE) is an evidence-based care model for older adults who meet a nursing-home level of care but live in community settings. These organizations blend funding from Medicare and Medicaid to integrate preventive, acute, and long-term care as well as services to address social needs. While many services are provided in PACE day centers, PACE organizations have adapted the delivery of services to meet patient needs during the COVID-19 pandemic.

This webinar, coordinated by the Better Care Playbook and the National PACE Association and made possible through support from the Seven Foundation Collaborative and West Health Policy Center, will highlight innovations adopted by PACE organizations during the pandemic to provide care for older adults with complex needs. Lessons shared will be broadly applicable to organizations serving vulnerable older adults in other settings during the pandemic as well, particularly through integrated health plan approaches. In addition, speakers will review state policy considerations to address the long-term needs of older adults requiring a nursing home level of care in the context of COVID-19.


A Safe Alternative to Nursing Homes

In a 2018 blog post, the Institute for Healthcare Improvement (IHI) describes PACE as “safe alternative to nursing homes.” While posted in 2018, this post is more relevant than ever in light of the COVID-19 crisis.

More than 1.8 million seniors over the age of 65 in the United States live in supportive care facilities, but many would choose to remain at home if they could. The following excerpt from IHI’s No Place Like Home: Advancing the Safety of Care in the Home report presents a program that provides nursing home-level care to patients in their own homes.

To optimize the care of nursing home-eligible individuals receiving care at home or in a community-based setting, in 1990 the federal government began offering states Medicaid waivers to enable experimentation with value-based service models. The Program of All-Inclusive Care for the Elderly (PACE), an initiative originally developed by San Francisco’s On Lok Senior Health Services, was among the first programs. PACE aims to avoid nursing home placement by providing a broad range of care services to Medicare and Medicaid beneficiaries who clinically require a nursing home level of care. The program provides flexibility for caregivers; offers tailored services that manage the complex medical, functional, and social needs of frail elders; and promotes adherence to home safety standards.

Congress authorized 10 PACE replication sites in 1986 and codified PACE as a permanent Medicare program in the Balanced Budget Act of 1997. To date, 31 states offer PACE options to frail elders; 90 percent of PACE enrollees are eligible for both Medicare and Medicaid.

Description of the Program

For individuals who are deemed eligible for a nursing home level of care by their state’s administering agency, PACE offers an alternative option: living in their homes and communities while receiving coordinated, highly tailored health care services spanning the care continuum. Eligible seniors are assigned to a specific PACE organization that includes an interdisciplinary team comprising clinicians and support service providers. The interdisciplinary team is responsible for conducting initial and periodic participant assessments, performing care planning, and coordinating 24-hour care delivery.

The program includes these components:

  • Initial and ongoing assessments by the interdisciplinary team
  • PACE center services (such as adult day and social programs, primary and preventive care, restorative therapy, nutrition services and meals, pharmacy, social services)
  • Transportation for participants
  • Mental health care services
  • Care coordination
  • Assistance with activities of daily living
  • Prescription medications
  • Emergency services

How the Program Works

PACE organizations provide a wide range of services, including adult day programs, primary and preventive care, nutritional support, pharmacy services, social services, transportation, and other support services. Members of the interdisciplinary team coordinate services, based on a comprehensive baseline needs assessment. Within 30 days of enrollment, beneficiaries receive in-person assessments conducted by the interdisciplinary team, including an in-home assessment by a team member. Additional assessments are conducted at least every six months thereafter. Care is provided at PACE centers, at home, or in the community through contracts with other community-based providers. PACE center safety standards, outlined in federal regulations, address wheelchair accessibility, handrails, safe water temperatures, housekeeping chemical storage, cleanliness, and infection control protocols.

PACE Interdisciplinary Team Members of the PACE Interdisciplinary Team

At a minimum, the assessments address the following health and safety concerns:

  • The home environment, including the ability to safely enter and leave the home
  • Physical and cognitive function
  • Medication use
  • Participant and caregiver preferences for care, including advance care planning and participant goals of care (person-directed care)
  • Socialization and availability of family support
  • Current health status and treatment needs
  • Nutritional status
  • Participant behavior
  • Psychosocial status
  • Medical and dental status
  • Participant language and cultural needs
  • Based on the assessment findings, the interdisciplinary team creates a tailored care plan with a strong prevention component. If the participant is hospitalized or enters a skilled nursing facility, the interdisciplinary team often participates in clinical rounds that involve the participant.

The program is funded by a combination of sources, including Medicare, Medicaid, and private payers. Reimbursement is a fixed per member per month fee that covers the entire spectrum of participant-tailored services that care for the whole person. Because PACE assumes the full risk of the participant, the organization may find it cost-effective to provide interventions that are not traditionally covered by Medicare or Medicaid. For example, if the interdisciplinary team determines that a participant needs to have an air conditioner installed in his or her apartment perhaps because of a pulmonary condition, the program could cover that expense.

Program Results

  • A 2014 federally supported evidence review suggested that PACE is cost-neutral relative to traditional Medicare. It also noted that PACE enrollees experience fewer hospitalizations than their counterparts in fee-for-service Medicare. Of the studies included in the review, the one with the strongest evidence rating found that PACE enrollees were nearly 30 percent less likely to be hospitalized than a matched comparison group.
  • A 2016 Commonwealth Fund report suggested that the original (On Lok) PACE program’s 30-day readmissions rate was half that of other Medicare beneficiaries.
  • A 2015 study found that PACE enrollees had a 31 percent lower risk of long-term nursing home admission than enrollees of Medicaid home- and community-based waiver programs, suggesting that PACE may help reduce long-term nursing home utilization.
    Approximately 93 percent of PACE participants report that they would recommend the program to a friend or relative.

Program Results

  • A 2014 federally supported evidence review suggested that PACE is cost-neutral relative to traditional Medicare. It also noted that PACE enrollees experience fewer hospitalizations than their counterparts in fee-for-service Medicare. Of the studies included in the review, the one with the strongest evidence rating found that PACE enrollees were nearly 30 percent less likely to be hospitalized than a matched comparison group.
  • A 2016 Commonwealth Fund report suggested that the original (On Lok) PACE program’s 30-day readmissions rate was half that of other Medicare beneficiaries.
  • A 2015 study found that PACE enrollees had a 31 percent lower risk of long-term nursing home admission than enrollees of Medicaid home- and community-based waiver programs, suggesting that PACE may help reduce long-term nursing home utilization.
  • Approximately 93 percent of PACE participants report that they would recommend the program to a friend or relative.
    To read other case studies and learn more about improving patient safety in the home, please download the No Place Like Home: Advancing the Safety of Care in the Home report.

This post was initially published by the IHI Multimedia Team on 10/4/2018. You can read this original post here.