PACE offers team-based care for seniors to remain at home

Caring for an aging loved one can be a stressful and frustrating process.  Caregivers are often faced with the choice of placing their loved one in a nursing home or taking on a multitude of roles themselves – providing a safe and functional home environment, managing medications, chauffeuring their loved one from appointment to appointment, negotiating with a team of doctors who may not communicate with one another – all while juggling the demands of their own families and careers. PACE of the Southern Piedmont believes it doesn’t have to be this way.

PACE, otherwise known as the Program of All-Inclusive Care for the Elderly, is an innovative model of care that provides both preventative and long-term care for those who might otherwise face placement in a nursing home.  Begin over 40 years ago in San Francisco, PACE has been in the Southern Piedmont for almost five years.

PACE is a team-based model of care based on the idea of effectively and efficiently treating patients with multiple chronic conditions outside of the hospital setting.  The PACE Interdisciplinary Team is made up of both professionals and paraprofessionals who take a comprehensive approach to care management: providers, homecare coordinators, transportation drivers, nurses, social workers, physical and occupational therapists, dietitians, recreational therapists, and others, who evaluate PACE participants and develop an individualized plan of care.

Through the IDT, PACE is able to provide participants with an impressive list of included medical care services: primary medical and nursing care, recreational therapy, meals and nutritional counseling, social services, pharmaceuticals and medical equipment, laboratory services and diagnostics, physical, occupational and speech therapy, skilled home care, personal care, podiatry, optometry, audiology and dental care.  PACE’s Care Coordinator of Covered Benefits helps each participant develop a personal plan of care that provides comprehensive health care services.

The ideal PACE participant is someone 55 or older who needs a little additional support to live independently in his or her home.  “There’s a wide variety of levels of care that we provide,” says Director of Outreach and Enrollment April Barnes. “We have some individuals who are higher need, and some just need support for transportation.  



A critical component of PACE is putting preventative support in place that sets seniors up to remain in their homes long term.  Barnes points out that Medicare can make it difficult for seniors to get the therapy and exercise they need on a regular basis, and often allow only 100 days of rehabilitative therapy.  “We extend that through our program,” says Barnes. “Our patients have rehab every single week whether they need it or not.”

The Day Health and Wellness Center is another critical component of the PACE program.  At the Day Health and Wellness Center, participants in the PACE program see their Primary Care Physicians and participate in rehabilitation programs.  They also eat lunch together and participate in social activities like BINGO, reading groups, arts and crafts, exercise, music and field trips. The average participant visits the Day Health and Wellness Center 2 days a week.

PACE works with participants to provide transportation to the Day Health and Wellness Center as well as other medical appointments and activities.   PACE aims to be a “one stop shop” model of care, coordinating and providing podiatry, dental, vision, behavioral health, laboratory and wound care services on the premises.  Most care is delivered during the day, but care is available 24 hours a day, 365 days a year.

Ultimately, PACE is a support system, not a replacement for caregivers.  Dedicated caregivers play an important part in every participant’s treatment plan, and PACE provides education for caregivers in matters like administering medications and transferring seniors from chair to bed to toilet.  Though the program’s focus is on allowing seniors to remain in their homes, PACE can also provide respite care, skilled nursing facility care, hospitalization and end of life care if needed.

To enroll in the PACE program, seniors must be 55 years or older, live in the PACE service area, qualify for a nursing home level of care, and be able to live safely in the community.  Applying is free, and there is no obligation to enroll. PACE participants’ care is paid for by some combination of Medicare, Medicaid and Private Funds. For PACE participants who are Medicaid eligible, their out-of-pocket costs will reflect their current financial ability to pay for the program.  “The cost is based on the individual’s income so it is different for everyone,” says Barnes. “We have some participants who pay $0 a month for PACE because of their monthly income and we cover all of their medical needs 100 percent.”

If PACE sounds like a good fit for you or a loved one, start the enrollment process by calling 704-887-3853.  The first step is usually the potential enrollee and their caregiver(s) visiting for a tour; if they are interested, they can start paperwork that day.  Various steps and assessments must take place to qualify, so the process can take between 30-45 days.