Focusing on the daily life of frail people

The PACE (Program for All-Inclusive Care for the Elderly) model was born in 1971 when a dentist and a social worker working for the San Francisco Department of Public Health in Chinatown-North Beach realized that older people were reluctant to move to a social residence when, instead, with some complementary services, they could continue to live in their own homes, in a more friendly and stimulating environment. Nearly fifty years later, PACE enjoys good health and "The Commonwealth Fund" has published a "Case Study" analysing its operation and results.

Choose candidates well

The program focuses on elderly people who, because of their health and social circumstances, are in need of support and services on an ongoing basis. To make the selection, a team consisting of a doctor, nurse and social worker carry out a general geriatric evaluation to determine if candidates could continue to live in their environment with PACE services and, for this reason, assessments of suitability and safety in the home and family environment, caregiver availability and the network of neighbours and friendships are a key element in the evaluation.

Offer global services

Each beneficiary of PACE has a personalized care plan that can be developed either at home in the community centre or a mixture of the two. The key to the model lies in the central axis of daily services: socialization (avoiding loneliness), food, personal washing, cleaning of the home or stimulation to exercise; while specialized services (doctor visits, physiotherapy, psychotherapy, dentist, podiatrist, etc.) are available on demand.

Integrate social and health services

The PACE model is a pure example of service integration. Note that it’s not a question of coordinating professionals, who in turn must attend multiple occupations in other programs, but the basic team: doctor, nurse and social worker, through an individualized plan that is periodically reviewed, are those that move an extensive team that should make it possible for each patient to receive the appropriate services in the suitable place. Whenever one of the beneficiaries of the program enters hospital, the basic team takes special care of the transitions: reconciling medications, checking adhesions and, above all, responding quickly to decompensations and urgent situations.

PACE had the vision of putting social and health resources in a single pot and in this way was able to finance the most suitable services so that people, who want it, despite their limitations, can continue to live in their home. If PACE did not exist, it’s likely that they would be forced to enter a social residence or, worse, they would suffer the excesses of fragmented medicine.

Improving results

No one can say whether PACE should be more expensive, but there are studies that claim that for Medicare the costs of the program can be up to 15% lower, while other studies believe it’s neutral. In any case, the Commonwealth Fund's document states that for the elderly and fragile, the deployment of tailored community services is not more expensive, given the savings that are found in avoidable hospitalizations, polypharmacy, visits to specialists, medical tests of little value etc. On the other hand, what does increase is the satisfaction of the beneficiaries.

Edward Wagner (creator of the Chronic Care Model) says that when multicronicity combined with frailty appears the clinical approach should no longer be the priority, so I am glad to know that PACE, after almost half a century of experience, when admitting a beneficiary into its program, puts the focus on the quality of their daily life, while the other elements, health care included, take a step down into the background.


Jordi Varela
Editor