Programs of All-Inclusive Care for the Elderly


National Pace Association
Kate B. Reynolds Charitable Trust
NC Foundation for Advanced Health Programs, Inc.
Association of Home and Hospice Care
North Carolina LeadingAge
NC Department of Health and Human Services
NC Division of Medical Assistance
NC Institute of Medicine
North Carolina Health News
National Council on Aging and Center for Healthy Aging
NC Get Covered
North Carolina Partnership to Address Adult Abuse


Disaster Resources after Hurricane Matthew

Thanks to the NC Rural Center for this Hurricane Matthew- Disaster Relief Information

The Rural Center is keeping our friends, neighbors and loved ones in our thoughts and prayers as Hurricane Matthew continues to impact communities across central and eastern North Carolina.  We've compiled a few of the many resources available to assist communities, small businesses and farmers.  If you would like to help, please consider marking a contribution to the North Carolina Community Foundation Disaster Relief Fund.

Important Resources:

The North Carolina Department of Public Safety is posting storm-related information online.  Visit this site for information about road conditions, shelters, food assistance and other storm recovery help.  

The U.S. Department of Agriculture (USDA) North Carolina Farm Service Agency (FSA) has a host of programs for to help farmers and livestock producers recover from heavy rains, flooding and other qualifying events related to Hurricane Matthew.  

The U.S. Small Business Administration has announced a disaster declaration for North Carolina counties affected by Hurricane Matthew.  The SBA offers disaster loans for small businesses, agricultural cooperatives, private nonprofits, homeowners and renters.

Seventeen federal agencies have partnered to form an online portal to help users access and apply for disaster assisted jointly through federal, tribal, state, local, and private sector partners.



NC Department of Health and Human Services, Division of Aging and Adult Services:


Webinars and Presentations

Demographics and Outcomes for Adult Protective Services in North Carolina for 2014-2015


"Proving PACE through Quality Measures"

North Carolina Quality Committee (October, 2015)

Amy Porter of Elderhaus presented to the National PACE Association annual conference on North Carolina's quality initiative.


National Council on Aging (NCOA) Webinar on Suicide Prevention and Aging Adults

Center for Healthy Aging Team (September, 2015)

In recognition of Suicide Prevention Awareness Month, this webinar featured expert speakers highlighting risk factors for suicide among older adults and successful strategies for preventing suicide, as well as a recently developed toolkit for senior centers on suicide prevention.


Capstone Performance Systems' Webinar Series on ICD-10 Preparation

(July - September, 2015)

Capstone sponsored a 5-session webinar event to help PACE programs transtition to ICD-10. You can view the webinars and download the handouts on their ICD-10 preparation page.


AARP Chief Medical Officer to NC Health Care Leaders on Coordinated Care

Dr. Charlotte Yeh, Chief Medical Officer of AARP Services, Inc. (July 2015)

A recent presentation by Dr. Charlotte Yeh, Chief Medical Officer of AARP Services, Inc, reflects how the principles and practices already integral to PACE also can have very positive outcomes when applied in other settings. Dr. Yeh described an AARP/United Healthcare pilot project on integrated patient-centered care management in a fee-for-service setting which demonstrated improved health outcomes and cost savings for patients and payors. Participants were supplemental policyholders with multiple chronic conditions and high acuity levels.  She noted the following key practice findings from the pilot:

  • Its about the WHOLE person
  • Health care happens at home
  • Cannot overlook the emotional connection
  • Listening to the consumer is critical


Mediture TruChart User Group Webinar

Brenda Vatland, Account Executive (July, 2015)

In this webinar, Mediture shares new software features and ways for PACE program users to collaborate.


Hoard and Healthy Ideas Webinars

Cristine Clarke, Ed. D., Coordinator, Carolina Geriatric Education Center, UNC Chapel Hill School of Medicine Division of Geriatrics (June, 2015)

If you missed Martha Lamb’s fascinating presentation via webinar on Hoarding or Mary Lynn Piven’s description of the deployment of Healthy Ideas (an evidence based depression screening and intervention program here in NC), they are now available on the Carolina Geriatric Education Center website’s mental health page.


Task Forces

NCIOM Task Forces of Interest

The NC Institute of Medicine is a quasi-state agency established by the NC General Assembly in 1983 to monitor, study, analyze and advise on health issues in NC. Currently, NCOIM is facilitating task forces on Alzheimer’s Disease and related dementia, mental health and substance abuse, and patient and family engagement.  North Carolina PACE Association is represented on the dementia task force by Karen Oldham, Executive Director of Senior CommUnity Care of NC.

All meetings are open to the public. You also may request to be added to their email notification list. More information about each task force, as well as meeting agendas and presentations are available on-line. These task forces offer an informal opportunity to mention PACE as another care alternative. 

The Task Force on Alzheimer's Disease and Related Dementia is held by the NCIOM in partnership with the North Carolina Department of Health and Human Services Division on Aging and Adult Services, AARP North Carolina, Alzheimer’s NC, the Alzheimer’s Association, and LeadingAge NC. The  Task Force work focuses on: statewide awareness and education, early detection, care quality and coordination, health system capacity, health professional training, access to treatment, home- and community-based services, long-term care, caregiver assistance, research, brain health, data collection, public safety and safety-related needs of individuals with Alzheimer's disease, legal protections and state policies for individuals living with Alzheimer's disease. The goal of the NCIOM Task Force is to develop a North Carolina Alzheimer’s Disease Action Plan to provide policymakers, funders, and stakeholder organizations with a common vision and action steps to address Alzheimer’s Disease and its effect on our state.

The Task Force on Mental Health and Substance Abuse focuses on the 548,000 North Carolinian’s with substance dependence or abuse and the 1.4 million North Carolinians reporting serious psychological distress over the last year. The Task force addresses issues from a global perspective and then focuses discussion and recommendations on the needs of adolescents and older adults. The NCIOM Task Force on Substance Abuse and Mental Health has three working groups: the cross-cutting group, the adolescent group, and the older adults group. The overall Task Force addresses topics affecting the whole population, including the array of services available, workforce needs, integrated care, and telebehavioral health. The older adult working group will look specifically at the need to develop a continuum of services for the older adult population. The Task Force is funded by the Kate B. Reynolds Charitable Trust with the goal of developing a vision of the ideal community-based, evidence-informed services for the prevention and treatment of mental illness and substance use disorders and a set of actionable recommendations (within 3-5 years) that could help communities move towards that system.



Making the Case for Aging in Place

June 30, 2015 by Taylor Sisk

This story originally ran in North Carolina Health News and was made possible by a grant from the Winston-Salem Foundation to examine issues in rural health in North Carolina.

North Carolina’s Program of All-Inclusive Care for the Elderly looks to expand into rural areas. State government has applied the brakes.

There’s a concept in Confucian philosophy called “filial piety,” which suggests that you should be good to your parents in their advanced years. A text titled The Twenty-four Filial Exemplars outlines key tenets of this philosophy, culminating with 滌親溺器, roughly translated as “He Washed His Mother’s Bedpan.”

As a rule, we don’t do a lot of bedpan washing for our loved ones these days, not in the Western world. Our most common approach to dealing with the latter stages of aging is to pack away our elders, long before any bedpan washing is required.

Often, it’s necessary. But not as often as we’re conditioned to believe.

The Program of All-Inclusive Care for the Elderly, or PACE, offers an alternative approach, a community-based one.

The PACE concept was born in the early 1970s in San Francisco’s Chinatown. The program was founded on the belief that whenever possible, the community’s elderly residents – immigrants to the U.S., primarily from Asian countries – should have their needs met in the community and continue to live in their homes. The commonly used term today is “aging in place.”

The first PACE facility opened in 1973. PACE programs now serve approximately 35,000 elders nationwide, about 1,350 in North Carolina.

According to Linda Shaw, the Cary-based NC PACE Association‘s executive director, PACE’s participants tend to be frail and generally have multiple diagnoses. Some 95 percent are dual-eligible, meaning they receive both Medicaid and Medicare.

More than half of the state’s counties are already experiencing population aging, a demographic shift in which the median age of the population increases significantly due to improved life expectancy and a drastic decline in birth rate. Map progression shows the changing number of people over 65 in each county.

The PACE model is now regulated by the federal Centers for Medicare and Medicaid. Participants must meet the Medicaid plan requirements for nursing home services.

But most participants aren’t in a nursing home because, Shaw said, with emphasis, “They don’t want to be in a nursing home.” Their families don’t want them to be in a nursing home either. “They’re capable of living at home safely with the support of PACE and their family members.”

“Our elderly population is growing faster than any other population,” she said. “That’s also the population that’s most expensive to serve.”

The PACE model, Shaw said, has proved to minimize costs.

But since last year, the state Department of Health and Human Services’ Division of Medical Assistance has placed a cap on new PACE enrollments and a hold on approval of new facilities. This at a time when NC PACE is eager to move into the state’s most rural regions.

Shaw is at a loss for why.

Read the rest of the article at NC Health News


Access Dental Care Delivers For PACE of the Triad

Written by Dr. Bill Milner, President Access Dental Care (June, 2015)

Ellen Smith, BS, RN, PACE of the Triad Center Manager, had seen the problem before.  As former supervisor for a hospice and palliative care agency, her patients needing dental care had to be shuttled from home to a local dentist and back home again.  What made matters worse, the caring dental staff was afraid to treat some of her fragile patients, wanting to refer them to a specialist in the area.  It was a wasted trip, a terrible use of resources and resulted in a patient still needing basic dental services.  Oral health, neglected during the illness process, was becoming an irritating source of pain and infection.

Ms. Smith had heard about Access Dental Care (ADC) through her nursing home contacts.  She knew this non-profit special care dental organization provided onsite care to skilled nursing facilities, group home day centers and HIV/AIDS patients in the surrounding area.  Could this be the answer for PACE of the Triad, a Program of All-inclusive Care for the Elderly responsible for providing comprehensive health care services?

“It was just too easy,” Ms. Smith said.  “ADC’s staff moved their two operatories of dental equipment into the clinic area and started treating PACE patients, many of whom had not seen a dentist in years.  Instantly, comprehensive dental services were now an integral part of our care routine.  We knew that poor oral health caused aspiration pneumonia, heart problems, septic issues, diabetes and cancer related complications.  Our job of managing the patient’s total health was now supported by these dental long-term care experts.” 

“ADC now comes two to three days a month and is a phone call away for emergencies.  Not only do they handle the difficult-to-treat patient, but they know how to communicate with responsible parties, explain treatment plans and include them in the decision making process.  They continue to see twenty plus patients a day, take x-rays, clean teeth, provide fillings, extract teeth and make dentures.  The patients simply roll or walk into the clinic, get the care they need and then go back to their daily activities.”

How did the contract work?

ADC had always charged nursing facilities a retainer fee plus billed Medicaid and private pay patients on a fee-for-service basis.  The retainer fee allowed the organization to break even, compensating it for daily transportation to facilities, billing and communication with responsible parties and the emergency on-call service.  Ms. Smith stated that “we started out with the same approach, but because we were paying for the individual services, our team had to review and approve every treatment plan. 

Teepa Snow

Patient Care at PACE of the Triad by members of the Access Dental Care Team

This was cumbersome for us and in some cases delayed treatment for patients.  Then I thought, we are on a capitated system, why not ask ADC to price out their services the same way?”  ADC did the numbers and determined their break-even cost per patient per month.  This included all services, even dentures.  Ms. Smith said, “This solved the problem.  ADC was extremely flexible as we added new patients, making sure that the per capita rate matched up with the amount of time they were spending taking care of patients.  Their main focus has always been quality care while being fairly compensated.”


Ms. Smith is proud of the program.  “Early on, PACE of the Triad made the strategic decision that the mouth was going to be part of the body in our comprehensive approach to health care.  Our future patients, being much more preventive minded, will expect routine dental care.  We feel good knowing that we have a program in place to serve their needs.”

Want to know more about Access Dental Care?  Visit their website, or call their Asheboro office at 336-626-7232. For information about PACE of the Triad, visit or contact 336-550-4046.