PACE Programs Colorado Springs CO

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Jun 23, 2026

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Helping Aging Loved Ones Stay at Home Without Sacrificing Medical Care

For many families in Colorado Springs, there comes a moment when a parent or spouse needs more medical support than a weekly check-in or occasional ride to the doctor can provide. Maybe it's a string of hospital visits, a fall that raises new concerns, or the slow realization that managing medications, transportation, and doctor's appointments alone has become too much. The instinct is often to start looking at nursing homes or assisted living, but for many older adults, that's not what they want, and it's not always what they need.

That's where PACE comes in. The Program of All-Inclusive Care for the Elderly is a Medicare- and Medicaid-approved model built specifically for seniors who qualify for nursing home-level care but want to continue living in their own home, apartment, or with family. Instead of moving a loved one into a facility, PACE brings a full medical team, therapies, transportation, meals, and social connection to them, coordinated through a single program rather than a patchwork of separate providers and appointments.

What Is PACE, and Who Is It For?

PACE stands for Program of All-Inclusive Care for the Elderly. It is a nationally established care model, regulated jointly by Medicare and Medicaid, that combines medical care, therapies, prescription management, transportation, meals, and social engagement into one coordinated program. Rather than seeing a primary care doctor here, a physical therapist there, and arranging separate rides to each appointment, PACE participants receive virtually all of their care through one team and often through one location: a PACE day center.

Who Typically Qualifies for PACE

PACE is designed for a fairly specific group of older adults, generally those who:

  • Are age 55 or older
  • Have been assessed by the state as needing a nursing facility level of care
  • Are able to live safely in the community (at home, with family, or in another residential setting) with the support PACE provides
  • Live within the program's approved service area

Many families are surprised to learn that needing nursing-home-level care does not mean someone has to move into a nursing home. PACE exists precisely because many seniors in this situation can continue living independently, or with family, if they have the right combination of medical oversight, therapy, transportation, and daily support. PACE can be paid for through Medicare, Medicaid (Health First Colorado), a combination of both, or through private pay, and the program's team can help families sort out eligibility and enrollment.

Rocky Mountain PACE: Colorado Springs' Program of All-Inclusive Care for the Elderly

Phone: 719-314-2327
Service Area: El Paso County, Colorado Springs and surrounding communities

About Rocky Mountain PACE

RockyMountain PACE is a program of Rocky Mountain Health Care Services, a nonprofit organization that has served the Colorado Springs community since 1976. Rocky Mountain PACE itself was established in 2008 and has grown to operate three centers throughout Colorado Springs, giving El Paso County families more than one convenient location for care, therapy, meals, and socialization.

The program's mission centers on helping older adults remain as independent as possible for as long as it is safe to do so. Rather than treating independence and medical care as competing goals, Rocky Mountain PACE is built around the idea that the right combination of coordinated medical support, in-home assistance, and community connection can allow many seniors to continue living in their own homes rather than transitioning into a nursing facility.

Who Rocky Mountain PACE Serves

Rocky Mountain PACE serves adults age 55 and older who live in El Paso County and meet the state's nursing-facility level of care criteria while still being able to live safely in the community. The program currently covers a substantial portion of Colorado Springs and surrounding zip codes, including areas in and around Monument, Fountain, Falcon, Peyton, and Black Forest. Because covered zip codes can expand as the program grows, families are encouraged to call directly to confirm whether their address falls within the current service area.

Services Provided

Rocky Mountain PACE participants receive coordinated access to a wide range of services designed to address medical, physical, social, and emotional needs in one program. According to the organization, services include:

  • Primary medical care from a PACE physician familiar with each participant's history and needs
  • Specialty medical care through contracted providers
  • Nursing care and medication management, including home delivery of prescriptions
  • Physical, occupational, and recreational therapies
  • Adult day center services, including hot meals, nutrition support, and social activities
  • Social work support and care coordination
  • In-home personal care and home health services
  • Door-to-door transportation to the PACE day center and to approved medical appointments
  • Respite care for family caregivers
  • Emergency, hospital, and nursing home care when medically necessary

Each participant's care plan is developed and regularly reviewed by an interdisciplinary team that includes professionals across roughly eleven disciplines, from physicians and nurses to therapists, dietitians, and transportation staff. This team meets routinely to discuss each participant's medical status, social engagement, and emotional well-being, adjusting the plan of care as needs change over time.

Locations

Rocky Mountain PACE operates three centers in the Colorado Springs area, giving participants options closer to home for day services, therapy, and medical visits:

  • Pikes Peak Avenue Center — 2502 E Pikes Peak Avenue, Suite 100, Colorado Springs, CO 80909
  • Explorer Center — 8595 Explorer Drive, Colorado Springs, CO 80920
  • Quail Lake Center — 1420 Quail Lake Loop, Colorado Springs, CO (the program's newest location, opened in 2025 to expand access in southern El Paso County)

Centers are generally open Monday through Friday during standard business hours. Families should call ahead to confirm hours and to schedule a tour, since hours and availability can vary by location.

How Enrollment Works

Enrolling in Rocky Mountain PACE typically begins with a phone call to the program's intake team, who can answer initial questions and schedule both a home visit and a medical evaluation. From there, the state determines whether the applicant meets the nursing-facility level of care requirement. Once approved, the new participant generally begins receiving services on the first day of the following month. Families should expect the process to take a few weeks from the initial call to enrollment, though timelines can vary based on individual circumstances.

Importantly, enrollment in PACE is voluntary and reversible. Participants are free to leave the program at any time and return to traditional Medicare and Medicaid benefits if their needs or preferences change.

Costs and Payment Options

Rocky Mountain PACE accepts Medicare, Medicaid (Health First Colorado), and a combination of both, and also offers a private pay option for those who do not qualify for either program. The PACE intake team can help families understand what they may be eligible for and walk through the application process for Medicare or Medicaid coverage before enrollment, which can ease one of the more confusing parts of getting started.

Why PACE Matters for Colorado Springs Families

Colorado Springs has a growing population of older adults, and many families here are navigating the same questions: how do we keep Mom or Dad safe and supported without uprooting them from the home and community they know? For seniors managing multiple chronic conditions, memory changes, or mobility limitations, the alternative to staying at home has often felt like a hard choice between a nursing facility and an unsustainable amount of pressure on family caregivers.

PACE offers a meaningful middle path. Because El Paso County is served locally by Rocky Mountain PACE, families don't have to coordinate care across distant providers or rely on a single overworked caregiver to manage transportation, medication schedules, therapy appointments, and meals. Having three centers spread across Colorado Springs, including the newer Quail Lake location serving the southern part of the county, also means more families can access care without long drives, which matters for both participants and the family members who often accompany them.

For adult children juggling careers, their own families, and caregiving duties for a parent, a program like PACE can be the difference between burnout and a sustainable, supported arrangement that keeps their loved one safely at home.

How to Get Started with PACE in Colorado Springs

If you think a PACE program might be the right fit for your loved one, here are the practical next steps:

  1. Confirm the service area. Call Rocky Mountain PACE at 719-314-2327 to confirm that your loved one's address falls within the current El Paso County service zone.
  2. Ask about eligibility. The intake team can walk you through the basic requirements, including age, level of care needs, and ability to live safely in the community.
  3. Schedule a home and medical evaluation. These assessments help determine whether your loved one meets the state's nursing-facility level of care criteria.
  4. Discuss payment options. Ask about Medicare, Medicaid (Health First Colorado), and private pay, and find out whether the team can help with the application process.
  5. Tour a center. Visiting one of the three Colorado Springs locations can help your family see firsthand what a typical day looks like, from meals and therapy to social activities.
  6. Involve your loved one in the decision. Whenever possible, include the person who will be receiving care in conversations and visits so the choice feels collaborative rather than imposed.

Most families find that simply picking up the phone and asking questions is the easiest way to find clarity. The intake team is accustomed to fielding questions from spouses, adult children, and even concerned neighbors who aren't sure where to start.

Related Categories on Seniors Blue Book

If you are exploring PACE, you may also find these related categories helpful in your search for senior support in Colorado Springs:

This article was researched and written by Seniors Blue Book. Seniors Blue Book connects seniors, families, and caregivers with trusted local senior care resources nationwide. Browse local listings, read expert articles, and order a free printed guide at seniorsbluebook.com.

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Coordinating Senior Healthcare Through PACE in Mobile, AL

Managing several medical conditions can become complicated for an older adult and their family.A person may need regular primary care appointments, rehabilitation therapy, prescription medications, transportation, and assistance with personal activities. Each service may involve a different provider, telephone number, or schedule.Family members often take on the responsibility of organizing these arrangements.When needs become more extensive, managing multiple healthcare services independently can feel overwhelming.For qualifying older adults in Mobile, Alabama, the Program of All-Inclusive Care for the Elderly offers a different approach.PACE combines comprehensive medical care, supportive services, and care coordination through one interdisciplinary team to help eligible older adults remain in their communities.Instead of treating every healthcare need as a completely separate responsibility, PACE evaluates the whole person and establishes an individualized plan.Mercy LIFE of Alabama operates this model through Trinity Health PACE.Located on Springhill Avenue in Mobile, the organization provides primary care, nursing, medications, rehabilitation, transportation, adult day services, personal assistance, nutrition, and other approved healthcare services.For families in Mobile and Baldwin Counties, understanding the PACE model can clarify whether this coordinated approach may be appropriate.What Is PACE?PACE stands for Program of All-Inclusive Care for the Elderly.In Alabama, the program is also called LIFE, meaning Living Independence for the Elderly.PACE is designed for eligible older adults who meet nursing-home-level care criteria but can continue living safely in the community with appropriate support.Main Program GoalsPACE aims to:Coordinate healthcare servicesSupport appropriate community livingAddress medical and social needsReduce fragmented careProvide necessary supportive servicesInvolve participants in care planningSupport families and caregiversPACE is not simply a transportation service, senior center, or home care agency.It is a comprehensive healthcare and supportive-services program.Mercy LIFE of Alabama's Care ModelMercy LIFE of Alabama operates as part of Trinity Health PACE.The program uses an interdisciplinary team to coordinate a participant's approved medical and supportive services.Primary CarePrimary care professionals evaluate and manage general medical needs.Nursing ServicesQualified nurses provide appropriate assessments, clinical care, and monitoring.Specialty CareApproved specialists address medical conditions requiring additional expertise.RehabilitationPhysical, occupational, and speech therapy may be included when necessary.MedicationsPrescription medication services are coordinated through the program.TransportationMercy LIFE arranges transportation for approved appointments and center attendance.Personal AssistanceHome care aides may provide help with daily activities.Social and Emotional SupportSocial workers, recreational therapists, and spiritual care professionals may contribute to the participant's plan.Verified Contact InformationMercy LIFE of AlabamaAddress: 2900 Springhill Avenue, Mobile, AL 36607County: Mobile County, AlabamaPhone: 251-287-8420Participant On-Call Support: Available 24 hours a day.The Interdisciplinary TeamOne of the defining features of PACE is team-based care.The team may include:Primary care providersNursesSocial workersPhysical therapistsOccupational therapistsRecreational therapistsDietitiansHome care coordinatorsPersonal care attendantsTransportation personnelOther qualified healthcare professionalsWhy Teamwork MattersA participant's medical needs can affect everyday functioning.For example, reduced mobility may influence transportation and personal care requirements.A medication change may affect appetite or balance.A coordinated team considers how these issues connect.Individual ParticipationParticipants should have opportunities to express their preferences and goals.Family InvolvementAppropriate family members may contribute information and participate in planning.Regular ReviewCare plans are updated as needs change.Primary Care and Chronic ConditionsMany PACE participants manage multiple medical conditions.Routine Medical NeedsPrimary care may include general assessment and treatment.Chronic Disease ManagementConditions such as diabetes or heart disease may require continuing evaluation.Medication ReviewThe team considers prescribed medications and potential interactions.Preventive CareAppropriate screening and preventive services may be coordinated.Changes in ConditionThe team evaluates new symptoms or important health changes.Specialist ReferralsSpecialty services may be arranged when the program determines they are medically necessary.Patients should understand the procedures for contacting the team between appointments.Rehabilitation Through PACESome individuals require therapy to maintain or improve everyday abilities.Physical TherapyTherapists may address mobility, strength, balance, and walking.Occupational TherapyTreatment may focus on dressing, bathing, and other daily tasks.Speech TherapySpeech-language pathologists may assess communication or swallowing concerns.Individual GoalsTreatment depends on the participant's condition and functional needs.Team CommunicationTherapists coordinate with other PACE professionals.Home ConsiderationsAppropriate recommendations may address equipment or functional challenges at home.PACE therapy is provided according to medical necessity and the approved care plan.Medications and Specialty ServicesMedication management can be complicated when several conditions require treatment.Prescription CoordinationMercy LIFE includes medications among its services.Pharmacy-Related SupportThe care team helps organize appropriate medication needs.Vision and Hearing CareThe program advertises these specialty services.Dental CareDental services may be available through its network.PodiatryFoot care is included among available specialty services.Mental HealthThe program also identifies mental health care.Equipment and SuppliesNecessary medical equipment may be covered according to the participant's plan.Other than emergency care, services generally require authorization by the PACE team.Supporting Daily Living at HomePACE recognizes that medical treatment alone may not be enough to support community living.Bathing and DressingEligible participants may receive assistance with personal care.Meal PreparationHome support may include appropriate help with meals.LaundryApproved household assistance may be available.Light HousekeepingHome care aides may help with selected tasks.Home SafetyProfessionals may assess functional needs and recommend appropriate equipment.Caregiver SupportFamilies may receive guidance related to daily responsibilities.The specific services and frequency depend on individual assessment.Transportation Through Mercy LIFETransportation can be a major challenge when several medical appointments are necessary.Mercy LIFE provides transportation to its center and approved off-site healthcare appointments.Center VisitsTransportation helps eligible participants attend scheduled services.Medical AppointmentsApproved specialist or other healthcare visits can be coordinated.Medication DeliveryMercy LIFE states that medications may be delivered to participants' homes as needed.AccessibilityDrivers can arrange appropriate accommodations within program capabilities.SchedulingTransportation arrangements must follow the care plan and program procedures.Emergency TransportationMedical emergencies should be handled through emergency medical services rather than ordinary PACE transportation.Adult Day and Social ProgramsPACE also addresses social and emotional needs.At the Mercy LIFE center, participants may enjoy:Arts and craftsGentle movementComputer classesPet therapyBingoTriviaHoliday celebrationsCultural eventsWhy Activities MatterParticipating in suitable activities may provide enjoyment and opportunities for connection.Recreational TherapyThe program uses structured activities to support engagement.Individual PreferencesNot every participant attends the same activities.MealsBreakfast and lunch are available during center attendance.Coordinated ParticipationAttendance schedules are based on individual needs.Nutrition and Social ServicesSome participants have medical conditions that affect eating or nutrition.Registered DietitianMercy LIFE identifies a dietitian as part of its care model.Individual PlanningRecommendations may consider medical diagnoses and medication-related concerns.Swallowing DifficultiesAppropriate clinicians assess swallowing-related needs.Food AccessHome-delivered meals may be arranged.Social WorkSocial workers assist with practical, emotional, and family concerns.Spiritual CareMercy LIFE also offers spiritual support according to participant needs and preferences.PACE Eligibility in MobileTo enroll, an individual generally must:Be 55 years old or older.Live in an approved PACE service area.Be assessed by the state as requiring a nursing home level of care.Be able to live safely in the community with PACE support.Age alone does not establish eligibility.Mobile and Baldwin County CoverageMercy LIFE serves approved locations within Mobile and Baldwin Counties.Families should verify their ZIP code.Level-of-Care AssessmentA formal assessment determines whether the individual meets the required care level.Community SafetyThe program must determine that the individual can reside safely in the community with available services.EnrollmentThe intake team explains assessments, documentation, and enrollment steps.Understanding PACE CostsFor individuals eligible for both Medicare and Medicaid, or Medicaid alone, covered PACE services generally involve no out-of-pocket charges.People who do not qualify for Medicaid may owe a monthly premium.Medicare-Only ParticipantsA monthly fee may apply.People Without Medicare or MedicaidOther monthly payment arrangements may apply, depending on eligibility.Approved ServicesPACE generally coordinates and authorizes covered services through its team and provider network.Outside ServicesParticipants should not assume that separately arranged nonemergency care will be covered.Review Before EnrollmentFamilies should obtain a clear explanation of coverage, premiums, providers, and service authorization requirements.Why PACE Matters in Mobile CountySome older adults need substantial healthcare support but want to remain connected to their homes and communities.Coordinated HealthcarePACE organizes several services through one team.TransportationParticipants can receive approved transportation assistance.Home SupportEligible individuals may receive personal care and household assistance.Family InvolvementCare planning considers appropriate caregiver participation.Access to ActivitiesThe center offers recreation and social opportunities.Ongoing AssessmentServices can change as medical and functional needs evolve.Expert Tip for Understanding PACEExpert Tip: Before enrolling, ask the PACE team to explain how the program will handle your existing physicians, prescriptions, specialist appointments, and hospital care.PACE is an integrated care model, so participants generally receive healthcare through Mercy LIFE and its authorized provider network.Understanding this arrangement is essential when comparing PACE with traditional Medicare or other care options.How to Get StartedStep 1: Contact Mercy LIFECall 251-287-8420.Step 2: Confirm Service AreaAsk whether the residential ZIP code qualifies.Step 3: Review Age and Care NeedsDiscuss the applicant's circumstances.Step 4: Contact ReferralsCall 855-287-8427.Step 5: Complete Required AssessmentsThe team reviews eligibility.Step 6: Discuss ServicesReview primary care, medications, home support, transportation, and therapy.Step 7: Understand PaymentConfirm Medicaid, Medicare, and possible monthly premiums.Step 8: Review EnrollmentMake sure the participant understands the program's provider network and care coordination rules.Frequently Asked Questions1. What does PACE stand for?PACE means Program of All-Inclusive Care for the Elderly. In Alabama, the program is also called LIFE.2. Where is Mercy LIFE of Alabama located?Mercy LIFE is at 2900 Springhill Avenue, Mobile, AL 36607. Call 251-287-8420.3. Who qualifies for Mercy LIFE?Applicants generally must be at least 55, live in the approved service area, meet nursing-home-level care requirements, and be able to remain safely in the community with support.4. Does PACE include medical care and personal assistance?Yes. Mercy LIFE provides coordinated primary care, nursing, medications, therapy, transportation, personal assistance, and other services according to individual need.5. Is Mercy LIFE free for Medicare and Medicaid participants?Participants with both Medicare and Medicaid, or Medicaid alone, generally have no out-of-pocket charges for covered services. People who do not qualify for Medicaid may owe a monthly premium.Connect Healthcare and Everyday Support Through PACEHealthcare becomes more challenging when older adults need several services at once.PACE offers a coordinated approach that combines medical treatment, personal assistance, transportation, and social support through one interdisciplinary team.Mercy LIFE of Alabama provides these services to qualifying older adults in Mobile and Baldwin Counties.Families can contact the program to explore eligibility, coverage, and individualized care options.Seniors Blue Book Profile: https://seniorsbluebook.com/senior-resources/mercy-life-alabamaFind Mercy LIFE on Seniors Blue BookExplore Mercy LIFE of Alabama's PACE program, eligibility requirements, and integrated healthcare services.

PACE in Mobile, AL

Some families reach a point where arranging each service separately no longer feels workable. The older adult wants to stay at home, but appointments, prescriptions, transportation, and daily assistance require more coordination than the family can easily provide. Understanding a different model of care may help clarify the options.PACE in Mobile, AL, is available through Mercy LIFE of Alabama for people who meet the programs requirements. This guide focuses on deciding whether to explore enrollment, understanding how care is coordinated, and preparing questions before making a change.What PACE meansPACE stands for Program of All-Inclusive Care for the Elderly. Medicare describes it as coordinated healthcare and support for eligible older adults who need nursing home-level care and can live safely in the community with program assistance. Mercy LIFE explains that LIFE, or Living Independence for the Elderly, is Alabamas name for this model. Participation involves an organized care arrangement, not simply purchasing one stand-alone service.The basic eligibility questionsMedicare lists four conditions: age 55 or older, residence in the service area, state certification of nursing home-level care needs, and the ability to live safely in the community with PACE support. Ask Mercy LIFE to assess the specific circumstances. The persons address and care needs must be reviewed; living somewhere in the Mobile region is not sufficient by itself to establish eligibility. Mercy LIFE of AlabamaPhone: 251-287-8420Location: 2900 Springhill Avenue, Mobile, AL 36607Mercy LIFE publishes medical and nursing care, prescriptions, specialty services, rehabilitation, transportation, nutrition planning, social services, recreation, and in-home support. Its service page states that participants receive healthcare through the program and its network and that nonemergency services require care-team authorization. Ask the team to explain how this would work for the prospective participant. Which needs would be addressed at the center, at home, or through another provider? How would appointments and medications be coordinated?Understand the effect on existing careBefore enrollment, list current doctors, specialists, pharmacies, equipment providers, and upcoming treatment. Ask which arrangements would continue and which would change.Do not assume every current clinician is in the program network. Ask how specialist care is arranged, how treatment recommendations are reviewed, and whom to call before seeking a nonemergency outside service.If there are scheduled procedures or active treatment plans, bring them into the discussion early. Request clear instructions for the transition rather than trying to coordinate two different systems without guidance.Develop a realistic picture of home supportExplain the persons daily routine, mobility, personal assistance, meals, and time spent alone. Describe what relatives can provide reliably and which responsibilities are difficult to sustain.Ask how the assessment determines the care plan and how the plan is reviewed. Include the participants goals, such as maintaining familiar routines or reducing the complexity of appointments.Questions to resolve include:Is the home address in the service area?What assessments and state determinations are required?How are current providers and medicines handled?What assistance would be recommended at home?How are concerns and changes communicated to the team?Review costs and enrollment termsPACE payment arrangements depend on Medicare and Medicaid circumstances. Medicare explains that participants with Medicaid do not pay a monthly PACE premium, while people without Medicaid may have premiums or other payment arrangements. Ask Mercy LIFE for an individualized explanation and the enrollment agreement. Confirm what is approved, how authorization works, and what financial responsibilities may arise outside the programs arrangements.Keep coverage changes coordinatedAsk how enrollment affects existing insurance and prescription coverage. Confirm the effective date and any required notices before changing a current policy or benefit arrangement.Request a clear explanation of the enrollment and disenrollment process. Knowing how participation begins and ends helps the person make an informed decision and plan for continuity of care.If another organization helps pay for care, include it in the review. Resolve questions with the responsible program rather than relying only on a general description of PACE.Make transportation part of the conversationMercy LIFEs service information describes transportation to the center and medical appointments. Ask how scheduling, pickup, access needs, and changes are handled for the individual participant.Explain steps, mobility equipment, or other practical issues at home. Confirm what support is provided and what the household must arrange. Ask how the program communicates if an appointment or route changes.Why PACE matters locally in MobileFor an eligible Mobile resident, the value of a coordinated model depends on how well it fits the persons home, medical needs, and daily life. Families should assess the full arrangement, including appointments, transportation, and communication.Relatives who live elsewhere can help prepare information, but the program needs an accurate picture of the assistance actually available near the participant. Identify a local contact and a backup when appropriate.Ask about continuity during severe weather or other disruptions. Clarify how the program shares instructions, coordinates care, and communicates changes in normal center or transportation schedules.How to get started1. Prepare a summary of current healthcare, daily assistance, and household support.2. Call Mercy LIFE of Alabama at 251-287-8420 to ask about screening.3. Confirm the service area and assessment requirements.4. Review care coordination, provider arrangements, transportation, and costs.5. Read the enrollment agreement and resolve remaining questions.6. Follow the programs instructions for an agreed enrollment date and care transition.Practical tip: Create two lists before the conversation: care we already receive and help we still need. This gives the team a clear starting point without assuming what the final plan will include.Related categoriesLIFE Programs Care Management Adult Day Services

Managing Senior Healthcare With PACE in NJ

Managing Senior Healthcare With PACE in NJManaging healthcare can become increasingly complicated as people grow older. What begins as an occasional doctor's appointment may eventually involve several specialists, medications, rehabilitation services, transportation arrangements, and personal care needs.For older adults with multiple health conditions, keeping everything organized can be challenging.Family members often step in to schedule appointments, communicate with healthcare providers, manage paperwork, and help loved ones follow treatment recommendations.Over time, these responsibilities may become difficult to balance with work and family life.For residents of Oceanport, Monmouth County, and surrounding New Jersey communities, coordinated senior healthcare offers an alternative to managing every service separately.BoldAge PACE of Oceanport provides comprehensive medical and supportive services through the Program of All-Inclusive Care for the Elderly, commonly known as PACE.Its interdisciplinary approach helps eligible older adults receive individualized care while continuing to live safely in the community.Why Senior Healthcare Coordination MattersMany older adults live with several chronic conditions.For example, someone may have diabetes, arthritis, and heart disease.Each condition may require different medications, monitoring, specialists, or lifestyle recommendations.Without effective communication between providers, care can become fragmented.Common Healthcare Coordination ChallengesFamilies may struggle with:Scheduling multiple appointmentsKeeping track of medicationsArranging transportationUnderstanding treatment plansCommunicating with specialistsCoordinating rehabilitationManaging follow-up after hospitalizationIdentifying necessary home supportUnderstanding insurance arrangementsThese responsibilities can consume considerable time.A coordinated care model helps bring services together.What Is the PACE Model?PACE stands for Program of All-Inclusive Care for the Elderly.It is a Medicare and Medicaid program designed for individuals age 55 and older who require nursing facility level of care but can remain safely in the community with appropriate support.PACE provides comprehensive healthcare and supportive services through an interdisciplinary team.Rather than requiring families to organize every service independently, the PACE team develops an individualized plan.Who May Be Eligible?Applicants generally must:Be at least 55 years oldReside in an approved PACE service areaMeet nursing facility level-of-care requirementsBe able to live safely in the community with PACE services at enrollmentBoldAge PACE of Oceanport serves all Monmouth County ZIP codes.Eligibility is determined through the applicable assessment and enrollment process.The Role of the Interdisciplinary Care TeamThe interdisciplinary team is central to PACE.Its members work together to evaluate participants and coordinate appropriate services.Professionals May IncludePrimary care providersNursesSocial workersPhysical therapistsOccupational therapistsDietitiansPersonal care staffActivity coordinatorsTransportation personnelOther healthcare specialistsEach professional contributes expertise to the care planning process.Why Team Communication MattersA participant's medical conditions can affect mobility, nutrition, daily activities, and medication needs.When care professionals communicate, they can consider these interactions while developing treatment recommendations.For example, an older adult experiencing balance problems may need medication review, physical therapy, and adjustments to everyday routines.A coordinated care team can assess these needs together.Primary Healthcare CoordinationPrimary care provides an important foundation for ongoing health management.PACE participants receive primary healthcare through the program's approved arrangements.Services May IncludeRoutine examinationsEvaluation of new symptomsPreventive careMonitoring chronic conditionsMedication reviewsRecommended laboratory testingCoordination with specialistsThe care team determines what services are medically necessary.Specialist Care and ReferralsSome older adults require treatment from several specialists.A person with heart disease may need cardiology services.Someone with complex joint problems may need orthopedic evaluation.A participant with neurological symptoms may require additional specialty care.PACE coordinates necessary specialist services through its authorized healthcare arrangements.Questions Families Should AskWhich specialists are available?How are appointments scheduled?Can existing providers be used?How does the PACE team receive specialist recommendations?Who coordinates transportation?What happens when urgent specialty care is needed?Understanding the referral process is important before enrollment.PACE generally requires care through its network or authorized providers, subject to applicable program exceptions.Medication CoordinationManaging several prescriptions can be challenging.A person may need to take different medications throughout the day.New prescriptions may also affect existing treatments.How Coordinated Medication Review HelpsHealthcare professionals can evaluate:Current prescriptionsPotential medication interactionsSide effectsDosing schedulesNew or worsening symptomsChanges in medical conditionsPACE coordinates covered medications as part of the overall care plan.Families should understand the program's pharmacy arrangements and how medication changes are communicated.Managing Chronic Health ConditionsChronic conditions can affect several aspects of daily life.Diabetes may require dietary planning and blood glucose management.Arthritis may influence mobility and personal care.Heart disease may require ongoing monitoring and medication adjustments.PACE helps coordinate appropriate treatment for these needs.A Whole-Person ApproachInstead of focusing only on an individual diagnosis, the care team considers how medical conditions affect:MobilityNutritionPersonal careRehabilitationTransportationEmotional healthEveryday activitiesThis approach can help align different services with the participant's overall goals.Rehabilitation and Functional SupportSome older adults require rehabilitation after surgery, hospitalization, or changes in mobility.PACE can coordinate medically necessary therapies.Physical TherapyPhysical therapy may address strength, balance, walking, and endurance.Occupational TherapyOccupational therapy may support everyday tasks such as dressing, bathing, and using adaptive equipment.Speech-Language TherapySpeech-language professionals may address communication or swallowing concerns.Rehabilitation plans should reflect individual goals and medical needs.Personal Care AssistanceHealthcare needs often overlap with difficulties completing daily activities.An individual may require assistance bathing, dressing, or moving around the home.PACE may provide personal care and home-based support when the interdisciplinary team determines these services are necessary.Questions About Personal CareFamilies may ask:What assistance is available?How are service hours determined?What happens when needs increase?How are caregivers coordinated?Are services available at home?How are urgent concerns addressed?The type and amount of support depend on the participant's care plan.Coordinating Care After HospitalizationA hospital stay can create new needs.A person may return home with changed medications, additional mobility limitations, or rehabilitation requirements.Without coordination, families may find discharge instructions difficult to manage.PACE can arrange approved follow-up services through the care team.Important Post-Hospital NeedsThese may include:Follow-up medical appointmentsMedication reconciliationPhysical or occupational therapyNursing supportPersonal care assistanceTransportationMonitoring of new symptomsThe care team can evaluate the participant's needs and adjust the plan.Transportation and Access to Medical CareTransportation is often a significant challenge for seniors who do not drive.Frequent appointments can place additional demands on family caregivers.BoldAge PACE coordinates transportation to its Oceanport center and authorized medical appointments.Potential BenefitsTransportation support may help participants:Attend scheduled healthcare visitsAccess rehabilitationParticipate in center activitiesMaintain regular medical follow-upReduce reliance on relatives for routine transportationFamilies should ask how transportation is arranged and what assistance is available.The Role of Social WorkersMedical care is only part of comprehensive senior support.Older adults may also experience concerns involving housing, family relationships, financial stress, social isolation, or access to community resources.Social workers can help assess psychosocial needs and coordinate appropriate support.Areas Social Workers May AddressCare planning concernsFamily communicationAccess to resourcesAdjustment to changing health needsEmotional supportCommunity living challengesTheir role complements the work of medical and rehabilitation professionals.Nutritional Services and Care PlanningNutrition can affect chronic disease management, strength, recovery, and everyday well-being.PACE may provide meals and nutritional counseling according to individual needs.Common Nutrition ConcernsDiabetes-related dietary needsHeart-health recommendationsWeight changesDifficulty preparing mealsHydrationFood preferencesSwallowing difficultiesThe care team may include dietary recommendations in the participant's care plan.How Families Participate in Coordinated CareFamily caregivers often notice changes in a loved one's health or daily functioning.Their observations can provide valuable information.With appropriate consent and respect for privacy, families may participate in care discussions.Helpful Family ContributionsReporting new symptomsSharing medication concernsDiscussing mobility changesAsking questions about care plansProviding information about daily routinesIdentifying safety concernsSupporting social engagementA good communication process helps everyone understand their responsibilities.Why Ongoing Reassessment Is ImportantHealthcare needs can change over time.A person may develop a new medical condition, experience a fall, or require additional assistance.PACE teams reassess needs and make appropriate changes to approved services.Changes Worth ReportingIncreased weaknessFrequent fallsNew confusionChanges in appetiteMedication difficultiesHospitalizationsReduced mobilityChanges in daily living abilitiesFamilies should contact the care team when meaningful changes occur.PACE Costs and CoveragePACE costs depend on the participant's Medicare, Medicaid, and other coverage circumstances.Eligible Medicaid participants generally do not pay a monthly PACE premium.Participants with Medicare but without Medicaid may be responsible for monthly premiums.PACE does not impose deductibles, copayments, or coinsurance for services approved by the care team.However, families should understand provider authorization rules and any applicable premiums before enrollment.Why Local Care Coordination MattersBoldAge PACE of Oceanport is located in Monmouth County and serves residents throughout the county.For families in Oceanport, Long Branch, Eatontown, Tinton Falls, Red Bank, Middletown, Freehold, and surrounding communities, local access to coordinated services can be valuable.The Oceanport PACE CenterThe center is located at:1075 Stephenson Avenue, Suite BOceanport, NJ 07757The program's regular center hours are Monday through Friday, 8:00 AM to 4:30 PM.Participants and families can call the local number for program questions and after-hours assistance.Expert Tip: Organize Care Around Individual GoalsSenior Care Planning Tip: Start by identifying what matters most to the older adult. Whether the goal is remaining at home, managing chronic illness, maintaining mobility, or participating in favorite activities, healthcare coordination should support meaningful personal priorities.Medical care and everyday living needs should be considered together.Frequently Asked Questions About PACE Care Coordination1. How does PACE coordinate healthcare?PACE uses an interdisciplinary team to assess participant needs and arrange approved medical, rehabilitation, personal care, and supportive services.2. Can someone keep their current doctor after enrolling?PACE generally requires healthcare through its own providers or authorized network. Families should ask whether a current provider can participate before enrolling.3. Does PACE cover hospitalization?Yes. Medically necessary hospital services are included in the comprehensive PACE benefit, subject to program requirements and applicable emergency-care rules.4. Can PACE help manage medications?Yes. Medication management and approved prescription medications are included in PACE's coordinated healthcare services.5. How do families contact BoldAge PACE of Oceanport?Families can call 732-592-3400 or connect through the organization's Seniors Blue Book listing.Find Coordinated Senior Care With BoldAge PACE of OceanportManaging several healthcare needs can be difficult for older adults and their families.A coordinated approach can bring medical treatment, rehabilitation, medication management, transportation, and personal support together.BoldAge PACE of Oceanport offers comprehensive services for eligible older adults throughout Monmouth County.Interested in learning how PACE can simplify senior healthcare coordination?Visit BoldAge PACE of Oceanport on SeniorsBlueBook.com to learn more about the program and connect with the team.You can also call 732-592-3400 for information about eligibility, enrollment, and available services.Understanding the available options can help families develop a more organized and supportive approach to long-term care.