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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.