Picking up the PACE to senior care

While health systems are developing new digital health platforms to help seniors age at home, a 50-year-old program may offer a platform for sustainability – and collaboration.

The fastest growing population in the U.S. are seniors, and they’d prefer to live out their days in their own homes. That’s putting pressure on the healthcare industry to find ways to care for them where they are.

And while a lot of the talk is focused on new concepts like Care at Home and AI-enabled platforms, PACE has been quietly serving that population for five decades. It could be a foundation upon which health systems can build new care coordination and management programs for seniors.

PACE (Program for All-Inclusive Care for the Elderly) was originally created in the 1970s and established in 1990 by CMS to give seniors on Medicare and/or Medicaid access at home to both medical and social services, with the goal of keeping them in their homes instead of nursing homes or similar facilities.

A capitated model built for the long haul

“There have been a multitude of models of care at home over the generations,” says Joan Kwiatkowski, the CEO of PACE Rhode Island since it was founded in 2005 and a board member of the National PACE Foundation. “The difference between PACE and some of these other home-based models is that we do so much more within the PACE model. We are paid at a capitated rate — meaning what I get is what I get. If I provide too much, I lose money. If I provide good preventative care, I’m probably saving up for when that participant hits a rainy day and requires more care and more expense.”

The key to the program is that it provides both medical care and social support in the home and at care centers.

“The PACE model provides center-based care — we have adult day centers, we have transportation that brings people in, and we have health centers at those day centers where they can see their providers,” Kwiatkowski says. “But we also provide in-home care: House cleaning, personal care, medical care, social work support, meals. For that capitated amount, I’m covering not only medical and clinical support, but also social support. It’s the full gamut of what keeps people healthy. That’s very different from a Hospital at Home model, which is very targeted toward the maintenance and care of a particular diagnosis or set of symptoms.”

Where PACE is — and isn't

As of 2026, there are 149 PACE programs operating through 273 PACE centers scattered across 31 states, with plans in the works to expand to all states. As expected, the programs are clustered around high-population areas with many seniors, and access is challenging in rural and remote regions – making Care at Home and digital health platforms even more valuable in those areas.

Many healthcare organizations see senior care as an opportunity to create new programs or platforms, instead of looking for what’s already working and finding ways to collaborate.

Kwiatkowski points out that the Hospital at Home strategy is mostly episodic, addressing a specific care condition for a limited period of time. That may work for hospital-based acute care needs, but as the senior population grows, hospitals need to rethink that care journey – just as they would for people living with chronic care needs.

And that’s where health systems may be missing an opportunity.

Insurer and provider in one

“Once somebody comes into the PACE program, they’re insured by PACE,” she says. “We’re both the insurer and the provider of care. They step out of their Blue Cross program, or whatever it is, and are now insured by PACE. … Other Medicaid insurers have risk corridors or other protections built in, so if they’re taking a loss on a particular individual or cohort, they’re making up some of that loss. I’m not. No one gets more money if we’ve overspent. That incents our group to really work at the top of our game in terms of preventative care, identification of issues, and clarifying goals of care — so that we know people’s preferences and aren’t struggling with end-of-life decisions during a crisis. It really incents solid planning.”

The technology base is there as well. For an EMR platform, PACE RI works with Intus Care, which has developed the CareHub specifically for PACE programs. Robbie Felton, who founded the company in 2019, says health systems haven’t yet figured out how to merge the clinical side with what PACE offers.

“People recognize that PACE is the gold standard of care for nursing home-eligible seniors — the best way to care for complex dual-eligible patients,” he says. “Many of these health systems have hundreds of thousands of people who fit that profile entering their systems annually. The thought process has been that PACE is a way to capture those individuals and improve outcomes with a more comprehensive care model.”

“The next step is thinking about: OK, PACE has a well-functioning interdisciplinary care team that can provide community support, social support, medical support, care coordination, patient engagement<’ he continues. “How do you scale that to the breadth of PACE-eligible individuals currently in your health system? And for a local health system, how do you do the same thing? I think there needs to be intentional collaboration between local health system leadership and local PACE programs — around how you work together to take the core competency of PACE and have a much broader impact across the hundreds of thousands of individuals who might fit the PACE profile in your area.”

The collaboration that isn't happening (yet)

PACE RI does have a contract with a Hospital at Home program in Rhode Island, Kwiatkowski says, but in the two years that that contract has been in place, there’s been very little activity.

That could be a missed opportunity. As Hospital at Home and Care at Home concepts become more mainstream, health systems are looking for areas of collaboration with community-based programs, such as health clinics, social services, mobile integrated health and community paramedicine programs.

Kwiatkowski feels that health systems aren’t yet motivated to go that extra mile and think of senior care as a collaborative journey.

“I’m having a hard time with the concept only because the reimbursement systems and the motivations would have to change for there to be a partnership that works for all parties,” she says. “And I say this without shame: I am much better at providing in-home care than hospitals. I am because we want to be in people’s homes, and because of the tools that Robbie’s company provides me with. Hospitals are not as nimble — and that’s by design. So I’m not saying it’s impossible, I’m just saying the incentives would have to change for it to be a successful partnership.”

Payers may move first

Felton is a bit more optimistic.

“One thing I’ll add: As much outreach as we get from health systems, we also get from payers,” he says. “Post-COVID, there’s been a national phenomenon where utilization-related costs for dual-eligible members have increased across basically every insurer. And payers and care management organizations have not figured out how to care for that top 5% of most complex members.”

“It makes complete sense for those top 5% to be in a PACE model,” he adds. “Whether a health plan is creating its own PACE program or figuring out ways to partner with local PACE programs, it’s the right thing to do for the members — and ultimately the right business decision. It’s just so difficult to really impact care in the most beneficial way within the confines of Medicare Advantage or any duals plan that doesn’t have the exact infrastructure a PACE program has to care for those patients.”