Northland PACE (Program of All-Inclusive Care for the Elderly)
- Need: Keeping older adults living safely and independently in their own homes.
- Intervention: Northland PACE plans and coordinates a wide range of healthcare, in-home, and day center services to promote independence at home, hoping to avoid or delay nursing home admission.
- Results: Older adults remain safely in their homes for a longer period of time with this support. The PACE program sites in North Dakota work to preserve, enhance, and, in many cases, restore the independence, health, and well-being of their participants.
Evidence-levelPromising (About evidence-level criteria)
According to the 2011 Report to Congress, the Program of All-inclusive Care for the Elderly, or PACE, "is an innovative model of care and an established Medicare benefit and Medicaid State Plan option designed to help the frail, elderly population continue to enjoy the comforts of home and community by delaying or altogether avoiding nursing home placement."
In 2008, North Dakota's Northland PACE started accepting clients, using the urban-hub approach with Bismarck and Minot as the urban hub cities and Dickinson as the rural site. The partnership shares administrative costs which makes it easier for Dickinson to support its smaller rural population.
Working with older adults and their families, PACE assists not only those covered by the Medicare and Medicaid programs, but patients with private insurance and those who are self-pay.
The program's core staff is an Interdisciplinary Care Team made up of doctors, nurses, social workers, physical/occupational/speech therapists, home care attendants, day/health center workers, transportation coordinators, dietitians, recreational staff, and van drivers. This diverse team membership brings information from many perspectives to better facilitate healthcare decisions.
The Rural PACE Pilot Grant Program, established under the Deficit Reduction Act of 2005 by Congress and administered by the Centers for Medicare & Medicaid Services (CMS), provided start-up funds.
Current funding primarily comes from Medicare and Medicaid (part of the Medicaid State Plan). Other sources of funding are private insurance and self-payment. Long-term care insurance has not provided reimbursement.
- A PACE Day Center with clinic
- Healthcare appointment coordination
- Transportation for appointments
- Provision of medications, eye glasses, hearing aids, and durable medical equipment
- Coordination of in-home services including personal care, housekeeping, meals, and other chores
- Provision of a continuum of care and assistance with transition to a higher level of care, such as assisted living or skilled nursing (Northland PACE in Dickinson is attached to a nursing home which provides a coordinated transition.)
- When needed, end-of-life care with integrity and compassion
Currently, there are 190 participants in the Northland PACE program between the Bismarck, Minot, and Dickinson sites.
In October 2014, Northland PACE received the 2014 American Health Care Association (AHCA) National Center for Assisted Living Not-for-Profit Program of the Year.
The Report to Congress on the Evaluation of the Rural PACE Provider Grant program illustrated the favorable results for implementing PACE in rural areas.
For additional information on the PACE model and its outcomes, including information on rural PACE programs such as Northland PACE, see:
Hirth, V., Baskins, J., & Dever-Bumba, M. (2009). Program of All-inclusive Care (PACE): Past, Present, And Future. Journal of the American Medical Directors Association, 10(3), 155-60. Free Full-text
The biggest challenges in starting a PACE program are:
- Complexities surrounding the creation of an interdisciplinary team
- Interpreting/adhering to federal regulations
- For example, North Dakota must elect PACE as a voluntary state option under its Medicaid Plan.
- Clarifying reimbursement
- Reaching participant numbers required for financial feasibility of an all-inclusive program such as Northland PACE
- Balancing numbers of healthy and chronically ill participants for financial stability
- Marketing and enrollment challenges
- Educating community physicians and other providers
regarding the long-term options for PACE
- Referral pipeline numbers needed to sustain the program
- Physicians may need to transition their patients' care to another provider
While Northland PACE did use some of the National PACE resources during implementation, a consultant was hired to address rural-specific issues related to starting up a PACE program.
Aging and aging-related services
Home and community-based services
November 21, 2014
Date updated or reviewed
March 14, 2018
Please contact the models and innovations contact directly for the most complete and current information about this program. Summaries of models and innovations are provided by RHIhub for your convenience. The programs described are not endorsed by RHIhub or by the Federal Office of Rural Health Policy. Each rural community should consider whether a particular project or approach is a good match for their community’s needs and capacity. While it is sometimes possible to adapt program components to match your resources, keep in mind that changes to the program design may impact results.