Program of All-Inclusive Care for the Elderly

The PACE model was developed to address the needs of elderly and frail elderly individuals who want to remain in the community and receive home and community-based services rather than receive care in a nursing home.  Once enrolled, the PACE Program provides all the medical care, social services, and personal care services required by the individual.

To receive PACE services under Medicaid, an individual must be financially eligible to receive Long Term Care Medicaid Services. In addition, there are four basic eligibility requirements. The Medicaid recipient must:

• Be 55 years or older;
• Be determined by the State Medicaid Agency  to need the level of care (LOC) required under the State Medicaid Plan for coverage of nursing facility (NF) services;
• Reside in an approved PACE service area; and
• Reside in a residence that meets health and safety standards with family members and others available to provide care (i.e., recipient can be safely served in the community).

Medicaid pays a monthly fee (capitation fee) for eligible individuals enrolled in PACE.  Most PACE participants are also eligible for Medicare and, when this is the case, the PACE Program receives a second monthly capitation payment from Medicare. 

Capitated financing allows PACE to deliver all the services PACE Participants need and not be limited to those services reimbursable under the Medicare and Medicaid fee-for-service systems.

Service Area.  Each PACE Program must define its service area and that service area must be approved by the federal Centers for Medicare and Medicaid Services (CMS) and the state administering agency (Medicaid).

PACE Center.  The PACE Program provides a PACE Center that includes a primary care clinic, areas for therapeutic recreation, restorative therapies, socialization, personal care, and dining that serves as the focal point for  coordination and provision of most PACE services.

In-Home Care.  The PACE Program provides additional care to the individual in the home, such as In-Home Personal Care Services and home health care.

Referral Services.  The PACE Program arranges, manages, and pays for all care referred to community providers, including hospital services, nursing facility care, emergency room services, physician visits, and ancillary services.

Federal regulations require all PACE Programs to provide a comprehensive array of services that include the following:

• All Medicaid-covered services, as specified in the State’s approved Medicaid plan;
• Multidisciplinary assessment and treatment planning;
• Primary care, including physician and nursing services;
• Social work services;
• Restorative therapies, including physical therapy, occupational therapy, and speech-language pathology services;
• Personal care and supportive services;
• Nutrition counseling;
• Medical specialty services including, but not limited to the following:
  • Anesthesiology,
  • Audiology,
  • Cardiology,
  • Dentistry,
  • Dermatology,
  • Gastroenterology,
  • Gynecology,
  • Internal medicine,
  • Nephrology,
  • Oncology,
  • Ophthalmology,
  • Oral surgery,
  • Orthopedic surgery,
  • Otorhinolaryngology,
  • Plastic surgery,
  • Pharmacy consulting services,
  • Podiatry,
  • Psychiatry,
  • Pulmonary disease,
  • Radiology,
  • Rheumatology,
  • General surgery,
  • Thoracic and vascular surgery, and
  • Urology;
• Recreational therapy;
• Transportation;
• Meals;
• Laboratory tests, x-rays, and other diagnostic procedures;
• Drugs and biologicals,
• Prosthetics, orthotics, durable medical equipment, corrective vision devices, such as eyeglasses and lenses hearing aids, dentures, and repair and maintenance of these items;
• Acute inpatient care to include:
  • Ambulance,
  • Emergency room care and treatment room services;
  • Semi-private room and board,
  • General medical and nursing services,
  • Medical surgical, intensive care, and coronary care unit,
  • Laboratory tests, x-rays, and other diagnostic procedures,
  • Drugs and biologicals,
  • Blood and blood derivatives,
  • Surgical care and anesthesia,
  • Oxygen,
  • Physical, occupational, respiratory therapies, and speech language pathology services, and
  • Social services;
• Nursing facility care to include:
  • Semi-private room and board;
  • Physician and skilled nursing services;
  • Custodial care;
  • Personal care and assistance;
  • Drugs and biologicals;
  • Physical, occupational, recreational therapies, and
  •  speech language pathology, if necessary;
  • Social services; and
  • Medical supplies and appliances.
• Other services determined necessary by the Interdisciplinary Team to improve and maintain the participant’s overall health status.

PACE uses an interdisciplinary team (IDT) to case manage all the services provided or arranged by the PACE Program for each participant.   Consistent with Federal regulations, the PACE Program IDT must be comprised of the following members:

• Primary Care Physician;
• Registered Nurse;
• Masters Level Social Worker;
• Physical Therapist;
• Occupational Therapist;
• Dietitian;
• Recreational Therapist or Activity Coordinator;
• PACE Center Manager;
• Home Care Coordinator;
• Personal Care Attendant; and
• Van Driver.

Only public and not-for-profit organizations are eligible to develop and operate PACE Programs.  All PACE programs are approved by CMS and State Medicaid.  Both federal and state agencies are required to monitor PACE programs on an ongoing basis and ensure that they comply with all state and federal regulations and provide quality care and services.

There are two organizations currently operating PACE Programs in North Carolina and a third organization with a PACE program in development.  They are:

1. Elderhaus, Inc. of Wilmington, NC - Elderhaus PACE began operations on February 1, 2008, and serves New Hanover and northern Brunswick counties. 
2. Piedmont Health Services, Inc. of Carrboro, NC - Piedmont SeniorCare began operations on October 1, 2008, and serves Alamance and Caswell counties.
3. St. Joseph’s of the Pines, Southern Pines, NC - St. Joseph’s of the Pines Independently for Elders is scheduled to open in the fall of 2010.
4. Other Programs in Development:

Otherareas with interest for PACE development include Asheville, Charlotte, and Greenville.

There are many areas in the State where the elderly population is sufficient to support a PACE Program.  Also, existing PACE Programs can develop satellite sites without completing the full application, review, and approval process.