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Innovations : elderplusprogram-pace


Integrated Programs

Title:  Hopkins ElderPlus: Program of All-Inclusive Care for the Elderly (PACE)


Hopkins ElderPlus: Program of All-Inclusive Care for the Elderly (PACE) (1996) 

Organization: Johns Hopkins Bayview Medical Center  

What They’re Doing: All Inclusive care for the Elderly supported by Per Member Per Month 

Innovation type: All-inclusive Care , Per Member Per Month 

Clinical Innovation: All-inclusive coordination of preventive, primary, acute, and long-term care services for a nursing home-eligible population, allowing them to remain living independently while maximizing support services and reducing the need for hospitalization. 

Financing Mechanism: Johns Hopkins Medicine participates in the Program for All-inclusive Care for the Elderly (PACE) which is a national program run by Centers for Medicare and Medicaid Services (CMS) . CMS pays Hopkins ElderPlus an upfront, risk-adjusted, per member per month (PMPM) fee in exchange for Hopkins providing all-inclusive care for the seniors enrolled in the program The program is responsible for providing all medical and supportive care to the patient population. While the program is designed to keep participants healthy and at home, if the seniors require acute care (ED or inpatient care) or long-term care (nursing home or rehabilitative care), the program must pay for the services using the PMPM fees. This incentivizes wellness promotion, prevention, and avoidance of unnecessary hospitalization.  

Kaiser Health News report on PACE.​


​​  Evaluation Type: Non-Experimental/ Qualitative Support

Evaluation plan: Organization’s evaluation includes reporting and tracking of multiple measures, i.e. hospital utilization, average length of stay, hospital readmissions within 30 days, nursing home utilization, advanced directives, immunization rates, falls, skin integrity, etc.  

External evaluation includes biennial, onsite surveys of the PACE program by the Centers for Medicare and Medicaid Services (CMS) with the Maryland Department of Health & Mental Hygiene (DHMH), and biennial Adult Day Care surveys by DHMH.  

Patient Health and/or Cost Outcomes:  

  • Reduced hospitalization: The program has a rate of hospitalization comparable to that of the general Medicare population, despite caring for a population of sicker, nursing home-eligible older adults at baseline.  In fact, HEP has lower hospitalization rates (3823 days/1,000 patient days/annum) than comparable populations in the nursing home (5247 days) and in Home and Community-based waiver programs (6447 days).  

Other Outcomes of Interest:  

  • Improved Independence: 96% of participants (who are all nursing home eligible) are able to remain living in their own home and or community.
  • Strong Patient Satisfaction: 95% of participants would recommend the program to a family member or friend.  


PACE® was one of three programs researchers identified as models of long term care that are effective, efficient and less expensive than traditional long term care in a study whose findings appear in the November 3, 2010 issue of the  Journal of the American Medical Association (JAMA) JAMA . 2010;304:1936-1943, 1948-1949.  

Target Population: High-risk nursing home-eligible elderly population living at home.  

Date of Implementation: January 1996  

Contact: Matthew McNabney, MD, Medical Director (Hopkins ElderPlus); 410-550-8679 ;

Multimedia: ;  

Where to learn more:  




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