In recent years, there has been a recognition of the importance of social determinants of health, including the impact of where a person lives on their overall health and well-being. This is especially true for older adults, for whom safe, accessible, housing with integrated health and long-term care services (such as home care, housekeeping, and nutrition support) is the key to remaining in the community.

Housing providers have been increasingly interested in seeking programs and developing relationships aimed at enabling older residents to remain safely in their homes for as long as possible. In Massachusetts, there are many organizations that operate programs designed to assist older adults. These range from organizations that provide companionship, villages that support affinity groups, home health agencies that provide in-home assistance with activities of daily living, adult day health centers, adult foster care, and care coordination programs.

The Program of All-Inclusive Care for the Elderly (PACE) offers all these services and more and has proven to be a valuable partner to housing agencies that operate affordable housing for older adults.

Massachusetts recently launched an initiative to expand PACE to every zip code in the Commonwealth, making this an ideal time for housing agencies to learn more about PACE and PACE-Housing Partnerships.

There are already many PACE-Housing partnerships in place across the state, and while these models can vary in their design and structure, all PACE-Housing models seek to maximize the ability of residents to remain in their homes through access to housing stabilization services, enhanced support, health-related services, and collaboration between PACE Organizations and housing partners.

This document is designed to introduce and provide examples of PACE-Housing partnerships to stakeholders in the housing arena (e.g., landlords, property managers, developers, etc.), and to highlight opportunities for housing agencies to further support tenants through relationships with PACE Organizations.

Continue reading this article by downloading the Considerations for Combining PACE with Housing PDF here.

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Nilda Goodridge couldn’t stop worrying about her mom, Sheila. At 87, Sheila lived alone in Cambridge. She grew increasingly isolated, cried often, and lost weight at an alarming rate. Nilda wasn’t sure what was happening to the strong, independent mother she remembered raising her, a woman who had risen at 4 a.m. for her job as a food service worker for a local hospital.

An elderly Asian woman stands in front of a bus she is about to boardBeing disabled herself, Nilda knew she needed help caring for her mom. She spoke with Sheila’s doctor, who recommended Cambridge Health Alliance’s PACE, or Program of All-Inclusive Care for the Elderly. The result, Nilda says, transformed both of their lives.

Three days a week, Sheila Goodridge takes PACE’s van to their adult day program in Cambridge, where she socializes with other older adults, enjoys musical performances and pet therapy, and expresses herself through art projects that she shares with her children and grandchildren. “I love coming here. There’s a lot going on and it keeps my mind interested,” says Sheila, whose laugh comes easily now. “I like the people I’ve met. I say that from my heart because it’s true.”

The colorful, light-filled site is just the start of PACE’s services for Sheila. The program provides her with a primary care physician and other medical professionals, some of whom see her at home when needed. The van transports Sheila to medical appointments, a task that Nilda says previously fell to her. “They took a whole lot of weight off my shoulders.”

What does PACE consist of?

As an interdisciplinary, coordinated program of health care and social services, PACE is designed to enrich the lives of lower-income adults aged 55 and older who typically qualify for nursing home care. “Our goal is to provide comprehensive services for them so they can stay in their homes safely,” says Tara Sherman, PACE’s director of nursing. The program promotes independence and helps participants continue to live in their own homes, which generally, they greatly prefer Sherman says.

In addition to two adult day programs — one in Cambridge and one Malden — PACE’s team of physicians, nurse practitioners, nurses, social workers, and many other professionals supply a striking array of services. Offerings range from exercise and assistance with chores, to personal care aides and mental and nutritional counseling, as well as physical, occupational, and speech therapy. As for any medications a participant may need, all prescriptions are covered in full and delivered to their home for free. Specialty care such as dental and optometry is also covered.

Cambridge Health Alliance (CHA) is dedicated to providing care for all, regardless of income. The structure of PACE reflects that core belief. Low-income older adults receive PACE services for free. More than 600 older adults from 13 cities in the region — including Cambridge, Arlington, Medford, Malden, Everett, and Revere — currently take part.

PACE is one of several CHA programs dedicated to serving the needs of older adults in the Boston-area, helping to fulfill the organization’s commitment to caring for all older adults in the community regardless of income or level of need.

Individualized care is key

PACE’s hallmark is one-on-one attention and care for each participant and family. That approach begins from the first day an older adult or caregiver inquires about the program. During the enrollment process, a team of PACE leaders talks through how best to enhance the participant’s quality of life and recommends a suite of services based on that person’s unique needs.

Every participant benefits from a custom treatment plan. PACE’s flexibility means it can “achieve the participant’s life goals in a way that a traditional fee-for-service practice isn’t able to provide,” says Serena Chao, MD, CHA’s geriatric division chief. Plans are updated every six months.

A group of elderly women sit in a drum circle with big and colorful drumsThe structure of PACE makes it possible to get to know elders in an intimate way. “When we visit participants in their homes, we get to see things that practitioners in offices never know about,” says Sherman, like an empty fridge or a shower stuffed with sweaters when the participant says they shower daily. PACE professionals gently build relationships and trust over time to address those issues, including assistance with daily living.

Meeting participants where they’re at

More than 90% of PACE participants are able to continue living at home, whether in a single family home, senior apartment, supportive housing, or assisted living. PACE maintains contracts with assisted living communities in multiple cities and also partners with the Cambridge Housing Authority. In three Housing Authority buildings, PACE offers supportive 24-hour personal care, such as housekeeping, meal preparation, assistance with appointments, medication reminders, and general orientation about what will happen that day. “If a participant falls or an emergency happens, someone is there for them,” Sherman says.

One beneficiary of PACE housing assistance is Tomiko Matsuda. Soon after she moved to the United States from Brazil, her daughter passed away suddenly. Matsuda lived for a time at the YWCA. When PACE got her into supportive housing with wraparound services, many of her medical conditions improved. She began attending the PACE adult day program. “Before I came, I was very depressed,” says Matsuda in her native Portuguese through an interpreter – another CHA service. “I lost my mother, my daughter, and my brother. But I’m happy now. I came out of my depression.”

Strengthening relationships

An elderly Black woman has her heart checked by a short haired nurseAs much as PACE benefits participants, its services are equally essential for caregivers. Adult children of participants may be raising their own children, work full time, or have other responsibilities. Caregiving alone can be an exhausting, never-ending job, especially taking care of older adults with mild to moderate dementia.

“We say to families, ‘We’re partnering with you,’” says Sherman. “Let us help with the medications and the showers so you can enjoy your time with your loved one. When your relationship isn’t so task-oriented, you can focus on really enjoying your [loved one].”

Twenty percent of current 65-year-olds will need long-term care for more than five years, according to U.S. government projections. CHA’s PACE program is one model for keeping older adults healthy and engaged. Once enrolled, there are no terms or time limits. They can stay in the program for life.

On June 2, 2022, 2Life Communities, Element Care, and partner organizations and funders launched the construction for the redevelopment of the J.J. Carroll BHA building that will have 142 additional affordable units for older adults in Brighton

It was a beautiful day on Chestnut Hill Avenue in Brighton, where old and new colleagues gathered around the construction site of the John J. Carroll apartments. The Boston Housing Authority, 2Life Communities, and its partners, including MassHousing, the City of Boston, and Element Care PACE gathered in celebration of the unveiling of the redevelopment of the property. The building was chosen for modernization and currently holds 64 units; the new construction plans will create 142 new units and an 11,000-square-foot PACE center.

Amy Schectman, 2Life’s President and CEO, led the ceremony and started the event by bringing to the stage the city’s new Mayor, Michelle Wu. As a longtime housing advocate, Mayor Wu celebrated the planning process, which was inclusive of its residents in the design process. She then applauded the team’s collaborative efforts, choosing to partner with Element Care to include a PACE center on-site, ensuring these residents can age in place with the services they need. She closed her speech by switching to Spanish to ensure everyone heard her message.

L-R: Jennifer Crampton, Wells Fargo; Mayor Michelle Wu, Secretary Marylou Sudders

Secretary Marylou Sudders of the MA Executive Office of Health and Human Services followed Mayor Wu, stressing the importance of upholding the value of respect. She described how we respect our older adults by ensuring they have affordable housing and long-term care in their community. She praised 2Life for its creativity and innovation and for making it a priority for residents to remain in their communities, stay active, be taken care of and thrive. Secretary Sudders, a supporter of the PACE model, described her vision of having more PACE/Housing partnerships: “We are taking this model across the State, we can do it in Boston, and we plan to do it across the Commonwealth.”

Undersecretary Jennifer Maddox of the MA Department of Housing and Community Development echoed Secretary Sudders’ praises for the PACE model of care for older adults, “a few retire in Florida, [but] most want to stay in the community with family and friends.” Amy Schectman described how PACE shares 2Life’s goal of focusing on “holistic and preventive care” and keeping residents in their units, adapting as they age, based on need.

At the Podium, Bob Wakefield of Element Care

MassPACE’s longest-serving Board Member and Executive Director of the Element Care PACE program, Bob Wakefield, closed the event with key takeaways – the importance of affordable housing, the strength of the PACE model, and collaborative efforts like the JJ Carroll renovation, that combine the two visions. Bob describes the JJ Carroll project as a particularly innovative partnership that he believes will “address the social determinants of health on a scale that has never been seen before.” With on-site amenities such as an urgent care center, Bob believes we are one step closer to eliminating the need for long-term care facilities.

The event’s energy was contagious. The group of people gathered at the event were those who worked day-in and day-out during the pandemic to ensure those they served avoided the deadly COVID-19 virus. Their tireless efforts allowed them to form and strengthen connections. Together, they are creating an inclusive and supportive environment that gives older adults the respect they deserve. 2Life’s board chair, Jeffery Sach, summarized the project ‘s mission: “to encourage aging with dignity in a supportive community.”

Negotiations continue among Senate Democrats on the contents of their partisan reconciliation package. NPA has learned that the amount of funding for HCBS, which includes PACE, has dropped from $400B to $150B.

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For the American public, one of the first signs of the COVID-19 pandemic to come was a tragedy at a nursing home near Seattle. On Feb. 29, 2020, officials from the U.S. Centers for Disease Control and Prevention (CDC) and Washington State announced the U.S. had its first outbreak of the novel coronavirus. Three people in the area had tested positive the day before; two of them were associated with Life Care Center of Kirkland, and officials expected more to follow soon. When asked what steps the nursing home could take to control the spread, Dr. Jeff Duchin, health officer for Seattle and King County, said he was working with the CDC to provide guidance, “but,” he acknowledged, “it is a very challenging environment, particularly with so many vulnerable patients, to manage an outbreak.”

It turned out the virus had already been circulating among Life Care’s residents for weeks by the time administrators took action, and soon it was tearing through the facility. By March 5, at least nine residents had already died of COVID-19, and a group of families whose loved ones were still inside held a desperate press conference. “Our families are dying. We don’t know what to do. Our calls for help aren’t working,” Kevin Connolly, whose father-in-law lived in the facility, told reporters. “We have limited resources to battle this disease, and I think somebody somewhere decided that this population of people wasn’t worth wasting resources on.”

Many long-term-care experts would say Connolly was right. The pace at which that first U.S. coronavirus outbreak spread through Life Care, killing dozens of residents in weeks, shocked the public. But for those familiar with long-term care, it wasn’t surprising. “We really failed in a lot of ways, historically but also during this pandemic, to value older adults,” says David Grabowski, a professor at Harvard Medical School and an expert on long-term care. That is to say, the U.S. health care system basically left its nursing-home residents as sitting ducks for a viral pandemic like COVID-19.

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