Aging in Place with Home-Based Care Possible for Nursing Home Eligible Adults

Many older adults would prefer to stay living in their own homes instead of being transferred to a long term care community.

The Program for All-inclusive Care of the Elderly (PACE) has been providing wrap-around care to participants in Montrose and Delta Counties for the past ten years. PACE is a Medicare/Medicaid managed care benefit for adults aged 55 or older who choose to live in their homes despite being certified by the state as nursing home eligible. The goal of the PACE program is to extend participant independence and enhance their quality of life.

Senior CommUnity Care is the Western Slope’s PACE provider and manages the program with a staff of paid professionals. Presently, there are two PACE day centers and office locations in Montrose and Eckert. Participants must be able to live safely at home within a PACE site’s geographic area.

The core of the PACE program is the interdisciplinary team.  The team works to provide comprehensive medical and social services to the PACE participants. This team includes a primary care physician, nurses, dietician, nursing aides, drivers, physical therapists, occupational therapists, recreational therapists and social workers. The interdisciplinary team meets daily and is responsible for determining care needs, allocating resources, coordination of all services, and development of a comprehensive care plan, which is developed for each individual participant.

The care plan addresses a set of functional issues that are relevant to the overall health of the older adult participant. These include cognition, emotional status, social activity, mobility, diagnoses, medications, nutrition and other activities of daily living. Payment for services and monitoring of the quality of the services is authorized and directed by the interdisciplinary team.

A PACE Day Center is a location where participants can receive primary care by meeting with a doctor or nurse in the clinic, receive rehabilitation treatments to improve strength and balance, enjoy recreational and social activities, participate in one-on-one or group therapy, receive spiritual support and enjoy a meal. The number of days a participant attends the day center will be discussed with the participant and determined through the assessment process.

By caring for frail, older adults through this model, prevention of acute illness and conditions can often be prevented, thereby reducing the number of emergency room visits and hospital re-admissions while allowing the individual to age in place in their own home.


Editor’s Note: This article was submitted by Erin Berge, Regional Marketing Director with Volunteers of America and may be reached at 970-275-1220 or by email at