This article was originally posted on National Advisory Committee on Rural Health Services. Read the full article here.

Although 1 in 5 older adults (65 and over) in the United States live in rural areas,1 there is inadequate access to long-term services and supports (LTSS)1, particularly home and community-based services (HCBS), to meet the complex needs of the population.2 Expansion of the Programs of All-Inclusive Care for the Elderly (PACE) in rural areas may help ameliorate this problem. The Committee selected PACE as a topic because of the model’s unique integration of health and human services and the program’s potential for serving rural elderly.

PACE is a Medicare program and Medicaid state option.3 It is part of a group of care delivery approaches focused on preserving seniors’ ability to live at home that includes Medicare Advantage and Medicaid HCBS. However, PACE is a unique, integrated care model that provides comprehensive health care and human services to frail older adults with chronic care needs. To be eligible for PACE, an individual must be 55 or older, live in the service area of a PACE organization, need a nursing home-level of care (as certified by their state), and be able to live safely in the community with assistance from PACE.4 Individuals enrolled in PACE continue to live in their community for as long as they are able due to the program’s coordination of preventive, primary, acute care, and LTSS.5 Because PACE is the sole source of services, there is a substantial decrease in administrative burden for PACE clinicians, participants, and caregivers. Clinicians are empowered to focus on patient-centered care, and participants and caregivers on better quality of life.

Evidence indicating cost savings and improved health outcomes for PACE participants, particularly for individuals who are dual-eligible for Medicare and Medicaid, continues to grow.6 After learning about PACE from experts and site visit stakeholders during the September meeting, the Committee believes that the model has great potential for rural areas. They were impressed with how the model addresses social determinants of health by focusing on high-quality medical care, access to community services, socialization, and safe and comfortable housing.

However, awareness of PACE as a viable option remains low in rural areas. Not all states have PACE organizations or approve PACE as a Medicaid option. The significant start-up funding and application process needed to establish PACE organizations are barriers to initial implementation as well as expansion. PACE organizations that successfully serve rural populations maximize existing partnerships and resources, but the Committee realizes that may not be feasible in under-resourced rural communities.

Based on their background work and presentations from experts and stakeholders, the Committee focused on several issues that potentially affect broad expansion of PACE in rural areas. This includes low patient volume, broadband and telehealth, limited awareness of the model, the rural hospital landscape, workforce shortages, and transportation challenges. They also focused on application, administrative, and start-up funding issues that influence the viability of PACE in all areas but pose greater challenges for the model in rural communities. Despite the barriers, the Committee believes PACE is an important option in long-term care and that expansion of the model in rural America is a worthwhile endeavor.

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