The Program of All-inclusive Care for the Elderly, or PACE, combines medical and social services for eligible people who need nursing-home-level care and can live safely in the community with program support. It operates in participating service areas, rather than being available everywhere.
Medicare lists four eligibility conditions: age fifty-five or older, residence in a PACE organization's service area, state certification of nursing-home-level care, and the ability to live safely in the community with PACE assistance.
Understand the breadth of the arrangement
PACE is more than attendance at a day center. Medicare describes a coordinated program covering Medicare and Medicaid services and additional care the PACE team determines necessary. Services may include home care, hospital care, nursing services, social support and transportation.
Before discussing enrollment, connect the person with the local organization for an explanation of eligibility, costs and how care would be arranged. Do not promise that enrollment preserves every existing provider relationship or that every requested service will automatically be approved.
Ask the person which current relationships, routines and supports are especially important to them, so those questions can be addressed explicitly.
Recognize the RN's place in the team
Federal PACE regulations require an interdisciplinary team that includes an RN along with other specified roles. The team is responsible for assessment, care planning and coordinating care across settings. Members must communicate relevant changes and work within applicable qualifications and scope requirements.
For a nursing position, clarify how the role connects center-based work, home visits, outside appointments and hospital transitions. Ask who communicates changes between these settings and how the RN can obtain information from other team members.
A broad interdisciplinary structure needs a practical method for deciding who takes the next action.
Turn assessment into a shared plan
The participant-assessment regulation includes an in-person RN assessment as part of the initial comprehensive process. It calls for attention to function, medications, preferences, social support, the home environment and other needs. Discipline-specific findings are consolidated into one plan, with reassessment requirements when circumstances change.
Use the program's assessment and planning procedures. This overview is not a replacement for their timing, documentation or service-determination requirements.
In a fictional example, a participant tells the visiting nurse that a planned support arrangement no longer works. The nursing contribution is to describe the change, bring it to the team and confirm the next step with the participant, rather than assuming the existing plan remains workable.
Evaluate communication in both directions
Ask how participants and caregivers raise concerns, receive explanations and learn what the team decided. Check how urgent issues are separated from routine requests.
For transitions, clarify who reviews outside recommendations and who confirms that an authorized service has been arranged. Document unresolved questions so they remain visible through a change of shift or setting.
After a hospitalization, use the follow-up guide to identify who will contact the participant and reconcile open items.
Related pages cover long-term services and supports, care plans across organizations and caregiver strain.
Sources
- PACE (accessed 2026-09-17) — Medicare.gov.
- 42 CFR 460.102: Interdisciplinary team (accessed 2026-09-17) — eCFR.
- 42 CFR 460.104: Participant assessment (accessed 2026-09-17) — eCFR.