Program for All-Inclusive Care for the Elderly (PACE)
Integration of physical and behavioral health services can help older adults living in rural areas to access needed healthcare services. The Program of All-Inclusive Care for the Elderly (PACE) model is designed to integrate care for frail older adults who are eligible for both Medicaid and Medicare (dual-eligibles). These dual-eligible individuals are more likely to have physical, mental, and cognitive conditions, and therefore, benefit from integrated care. Some PACE programs are targeted toward all older adults who meet the minimal acuity levels required for nursing home care.
PACE services are provided by interdisciplinary teams, which are responsible for coordination of 24-hour care delivery. PACE provides all Medicare and Medicaid benefits, which include:
- Adult day care
- Meals
- Social services
- Transportation
- Primary care
- Nursing home care
- Home care
This integrated model of care aims to improve the quality of life of older adults with chronic care needs by providing services in the community when possible. In rural communities, PACE programs are located either in a larger healthcare system or in a local agency or organization.
Examples of Rural PACE Programs
- Northland PACE, which serves older adults in Dickinson, North Dakota, coordinates healthcare and home care services for enrolled patients through care teams. This team includes a range of providers, including physicians, nurses, social workers, licensed therapy professionals, and home care attendants.
- HopeWest offers PACE to patients in rural western Colorado. The organization integrates multiple services related to hospice and palliative care, including grief services.
Considerations for Implementation
The high start-up costs for designing and implementing PACE means rural health networks may need to look for additional funds. As PACE programs typically enroll patients based on service area, rural PACE programs may find it difficult to maintain sufficient enrollment. In addition, rural communities should be aware that program enrollees may only see physicians that participate in PACE. PACE program leaders should communicate with enrollees about their choices within the PACE program to ensure that patients still feel in control of their healthcare management. Program leaders can also consider applying for a CMS waiver to allow enrollees to use community physicians in addition to PACE providers. The National PACE Association has information to help communities develop their own PACE program.
Resources to Learn More
Quick Facts: Programs of
All-Inclusive Care for the Elderly (PACE)
Document
Presents an overview about Medicare programs for older adults and people over 55 with disabilities. Discusses
who is eligible to enroll, how it is financed, and services provided.
Organization(s): Organization(s): Centers for Medicare & Medicaid Services
Date: 12/2025
Programs of
All-Inclusive Care for the Elderly in Rural America: Policy Brief and Recommendations to the
Secretary
Document
Describes the challenges and facilitators of rural PACE programs and offers recommendations to improve rural PACE implementation.
Organization(s): National Advisory Committee on Rural Health and Human Services
Date: 3/2023