America is aging, and with this demographic shift comes a critical challenge and a unique opportunity. By 2030, one in five Americans will be 65 or older, and the U.S. Census estimates by 2034, the number of older adults will outnumber children for the first time in our country’s history. This profound change requires a new approach to supporting healthy aging across the lifespan.

Our current health care system, often focused on treating acute illness in hospitals, is not fully equipped to meet the complex needs of a population living with multiple chronic conditions. Yet there is cause for optimism: innovative strategies are emerging, and health centers are often at the forefront of this transformation. Many ACH members are leading a shift in aging well and senior care through PACE or Program of All-Inclusive Care for the Elderly.

What is PACE? A New Standard for Senior Care

PACE is an innovative, community-based model that provides comprehensive medical and social services to eligible older adults who want to age well at home and avoid moving to nursing home care for as long as possible. Many PACE participants are dually eligible for Medicare and Medicaid. The program’s core philosophy is that older adults are best served in their homes and communities, where they can maintain their independence and quality of life.

Once enrolled, participants receive all care through a single, coordinated program. At the heart of PACE is an interdisciplinary team of health care professionals, helping to manage a participant’s care as holistically as possible. A team may include a doctor, nurse, social worker, physical therapist, and others who work together to develop a personalized care plan. This team manages everything from primary and specialty medical care to prescription drugs, transportation to appointments, home care, meals, and social activities.

The results are powerful. PACE participants have a 24% lower hospitalization rate and a 16% lower rehospitalization rate compared to their peers in other care models. PACE participants also show reduced rates of depression, which can be common in older adults who age in place alone. These outcomes reflect improved health outcomes for participants, as well as increased efficiencies for emergency departments and the wider health care system.

Community Health Centers: An Ideal Home for PACE

Health centers are natural partners for many PACE programs because both are built on a foundation of integrated, patient-centered care. For decades, community health centers (CHCs) have been leaders in providing comprehensive services to rural and underserved populations, addressing the many medical and social factors that influence health.

By combining the strengths of a CHC with the PACE model, organizations can create a powerful ecosystem of support that truly meets the needs of their aging community members. Here are three examples of community health centers doing just that:

North East Medical Services (NEMS), California

NEMS has a long history of serving the Asian American community. NEMS PACE exemplifies culturally responsive health care, with a welcoming environment that includes primary care, physical and occupational therapy, transportation, and healthy lifestyle amenities like an activity room, indoor garden and meditation space. NEMS PACE’s approach demonstrates a deep understanding of how to honor and support elder communities in a way that is both clinically excellent and culturally sensitive.

Said Janet Bernet, PACE Program Director, “NEMS PACE fills critical gaps such as transportation, caregiver support, and the loneliness epidemic by offering engaging activities and integrated support services. The program is dynamic and evolves with each participant, growing alongside their needs and offering a custom care plan at every stage of aging. Unlike other predefined models, PACE puts the participant at the center and sets the gold standard for integrated care for the frail elderly population.”

Jordan Valley Community Health Center (JVCHC), Missouri

Serving a large area in Southwest Missouri, JVCHC has integrated PACE into its robust system of care. Through the Jordan Valley Senior Care program, they provide a wide range of services, including primary care, dental services, mental health support, and transportation. By leveraging the health center’s existing resources and network, they ensure that seniors in their community have access to all the care they need to stay safe and healthy at home. 

JVSC Pharmacist Jordanna Jones told the Springfield News-Leader that the approach is integrated and simplified with strategies like “pill packing,” to make it easier for seniors to adhere to their medicines. She explained, “at a typical pharmacy, you might have five or six prescriptions, and two are filled this day, two are filled that day, or you might get a 90-day supply of this and a 30-day supply of that. “At PACE, their (prescriptions) are filled on the first of the month, so they get their medications just a couple days before the first of the month, every month.”

Jordan Valley Senior Care bus.
One important PACE strategy is making transportation easy for participants. Shown here is a Jordan Valley Senior Care bus.

Lynn Community Health Center (LCHC), Massachusetts

In partnership with Greater Lynn Senior Services, LCHC established Element Care to bring the PACE model to the North Shore and Merrimack Valley of Massachusetts. The program provides a comprehensive range of preventive, primary, and acute services, with a PACE team that is led by a primary care provider from the health center. This partnership exemplifies how collaboration between a community health center and a social services organization can create a seamless, integrated system that empowers seniors to remain independent.

Recognizing that many older adults not only struggle with medical care, but also affordable housing as they age, many PACE programs incorporate stable housing in their model. With the YWCA of Greater Newburyport, Element Care recently broke ground on an affordable housing expansion project that will create an additional 48 housing units for seniors.

Image from an affordable housing groundbreaking ceremony with Element Care and YWCA Greater Newburyport.
Element Care recently broke ground on new affordable housing with the YWCA Greater Newburyport.

PACE Programs Offer A Path Forward

Aging well is a gift in America, and meeting the growing need of older adults will require health centers and the U.S. health care system as a whole to embrace thoughtful planning and innovation. Promising models like PACE offer a path forward, shifting care from reactive, costly episodic care to proactive, person-centered support. 

This framework benefits communities and the healthcare system by helping to bend the cost curve. The National Council on Aging notes that 93% of older adults have at least one chronic condition, and nearly 80% have two or more. By prioritizing models like PACE, health centers and communities can better manage chronic conditions, prevent hospitalizations, and improve the overall quality of life for America’s seniors.

Learn more about healthy aging and the PACE model.

 

 

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