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Rural PACE Providers:
The Path from Interest to Start-Up

New PACE programs begin with a desire to provide high quality care, in the community, to older people with chronic care needs. Translating this desire into a start-up plan requires a thorough understanding of the PACE model of care, the community a prospective PACE program will serve, and your own organization. With this information, a prospective rural PACE sponsor can develop a sound business plan and apply for the regulatory authorizations needed to proceed.

For most organizations, the assessment and planning process will address both new and familiar considerations. As a result, in some areas the organization may be able to refer to its experience while in others innovation will be required. This is particularly true for organizations seeking to develop rural PACE programs. Rural PACE programs adapting the model to serve their communities today will generate insights that will guide future rural programs.

Objective and Overview

Past experience tells us that PACE programs pass through four general phases in completing their assessment and planning process:

  1. Understanding the PACE Model
  2. Assessing Community Needs
  3. Organizational Commitment and Capacity
  4. Planning and Development/PACE Provider Application

This guide is designed to help organizations that wish to serve a rural area navigate through each of these distinct phases, identify what they need to accomplish in each phase, and access technical assistance resources available to them. Each phase is presented in terms of objectives, activities, milestones and resources particular to that stage of decision-making. The last part of this guide describes how the interested organization translates its plan into an operating a PACE program.

At each phase, the National PACE Association (NPA) and a number of Technical Assistance Centers (TACs) are available to assist you with expertise, support and counsel throughout the development phases. If you have any questions, please call NPA at (703) 535-1517. For further information regarding TACs, please visit our web site at www.NPAOnline.org.

FIRST STAGE: Understanding the PACE Model

Prospective providers of PACE in rural areas will need to understand the model as it is currently designed and implemented in order to develop adaptations that will allow it to succeed in rural areas. Developing this understanding across a team of management and clinical leaders will form a foundation for moving forward within the organization.


  1. Gain an understanding of the PACE model's program and service requirements.
  2. Understand scope and extent of current PACE experience.
  3. Determine opportunities for flexibility in the PACE model.
  4. Understand the stages of development for initiating a new PACE program.
  5. Assess availability and cost of resources to assist in decision-making and start-up.


  1. Acquire and review information about the PACE model and current status of PACE providers.
  2. Assemble internal work group/team.
  3. Establish a timeline and work plan for completing an assessment process.

Prospective PACE providers can benefit enormously from the expertise of existing PACE programs. One of the best ways to understand the PACE model is to visit an operating PACE program. Technical Assistance Centers may arrange these site visits as well as initial on-site presentations and assessment.

Based on its understanding of the PACE model and internal interest, the organization is asked by its governing body to assess demand for PACE services and the community's need for services.

Public Resources

  1. PACE Program Fact Sheet
  2. NPA Calendar of Events
  3. PACE FAQs
  4. National PACE Association (NPA) Fact Sheet
  5. PACE in the News
  6. Developing PACE Education Series Library
  7. PACE Profile
  8. An Overview of Self-Assessment Considerations
  9. Setting the PACE for Rural Elder Care: A Framework for Action
  10. Rural PACE Issue Briefs

SECOND STAGE: Assessing Community Needs

The development of a PACE program requires an understanding of the potential demand for services, viewed in the context of existing community relationships and services. This understanding determines if there is adequate demand to support a new PACE program and lays the foundation for establishing referral networks that will help the program build census, contract for services to meet PACE participant needs, and foster public support. Assessing community relationships and existing services is an opportunity to gather information about the resources present in the proposed service area that may be used to implement a PACE program. In addition, the assessment is an opportunity to educate other stakeholders and/or referral sources in the service area about the PACE model so they can be potential partners.


  1. Quantify the potential demand for services.
  2. Describe access and referral patterns affecting potential enrollment.
  3. Describe existing services for similar populations.
  4. Identify potential partnerships.
  5. Build community support.
  6. Assess state support.


  1. Analyze demographic and state data to estimate the potential population your program could serve.
  2. Contact community health, housing and aging service providers to discuss PACE.
  3. Discuss state support for a rural PACE program with state Medicaid and Aging agencies and local legislators.
  4. Begin to document critical factors affecting development of PACE in your area (e.g., demographics, community resources and relationships, and state support).

Prospective PACE providers can work with NPA or a TAC to analyze demographic data available from the U.S. Census Bureau and state agencies. Assistance also is available for conducting a community needs assessment. NPA and the TACs can assist with materials and presentations for outreach to community organizations and state agencies.

Based on its understanding of the potential demand for PACE services and community support, the organization receives commitment from its governing body to develop a full organizational analysis related to initiating a rural PACE program.

Public Resources, as listed in First Stage
Rural PACE Assessment Instrument - Section 1 (all), Section 2 (Critical Factors 1-3)

THIRD STAGE: Organizational Commitment and Capacity

Having identified the opportunities and challenges for a PACE program based on demographics, community needs and state interest, a prospective PACE program then will need to assess its internal strengths and weaknesses. Consideration of the external and internal factors that will determine a PACE program's success is applied to the development of a business plan. The business plan is the basis for the organization to make a formal decision on whether to move forward with development of a new PACE program.


  1. Assess federal and state regulatory requirements and implications for PACE.
  2. Describe the organization's critical factors for moving forward and assess the need for outside support.
  3. Outline the key questions/factors to be addressed by the decision-making plan.
  4. Complete a business plan that will present a recommendation to the organization's governing body.


  1. Gather information and complete assessment process.
  2. Establish a timeline and work plan for developing a business plan.
  3. Explore and identify options for potential relationships/partnerships with community organizations.
  4. Develop a business plan and present it to the organization's governing body.

Based on the business plan, the organization commits resources to a timeline and work plan for start-up.

TACs can assist with organizational assessments and the development of a business plan for presentation to an organization's stakeholders and governing body.

Public Resources, see First Stage
NPA Membership Resources

  1. Demographic Report
  2. Developing PACE Education Series
  3. Exploring PACE List Serve
  4. Guide to PACE Site Selection and Center Development
  5. State Assessment
  6. PACE Financial Proforma Baseline Scenario

FOURTH STAGE: Planning and Development/PACE Provider Application

A decision to move forward with a new PACE program will require the completion of a Provider Application, access to start-up funds and development of the infrastructure needed to provide services. The prospective PACE sponsoring organization will need to work with state and federal agencies, internal and external funding sources, community organizations and health care providers to assemble an operational PACE program.


  1. Secure financing and risk insurance.
  2. Assemble management team and start-up staff.
  3. Establish administrative and information systems.
  4. Obtain approval of PACE provider application including any necessary waivers, to establish PACE provider status with state and federal agencies.
  5. Establish marketing strategies.
  6. Establish an operational PACE center along with any related alternative care delivery sites.


  1. Develop program policies and procedures.
  2. Prepare PACE provider application and any necessary waiver requests.
  3. Identify target audiences for development of referral network.
  4. Develop marketing plan and materials.
  5. Design, construct and equip PACE day center.
  6. Hire and train staff.
  7. Select, install and train staff on information system.
  8. Establish financial accounting system and procedures.


  1. PACE provider application and any necessary waivers are approved; provider agreement is signed.
  2. PACE center and any alternative delivery sites are operational.
  3. Organization is ready to offer services and begins enrolling participants.

Once an organization has decided to proceed with PACE, TACs are available to assist with the initial planning and development of the PACE program, including the development of the PACE center, hiring and training center staff, start-up and preparation of the PACE provider application. TACs also provide ongoing consultation once an organization is fully operational and has begun providing services to participants. TACs provide support through telephone consultation, on-site visits, intensive trainings and resource materials.

NPA Membership Resources

  1. Core Resource Set for PACE (CRSP) - a compendium of PACE program operational resources to assist providers in PACE development and expansion
    • PACE Operating Resources - resources for administering and operating a PACE program
    • A Guide to Preparing the PACE Provider Application - resources for preparing the PACE provider application and for the Center for Medicare and Medicaid Services (CMS)/state on-site review
    • PACE Financial Proforma - a financial model for forecasting budgets and financial performance, including a Financial Baseline Scenario and Proforma User's Guide
  2. Baseline Scenario and Proforma User's Guide
  3. Networking list serves
  4. Federal and state advocacy
  5. Updates on federal and state policies
  6. NPA communications
  7. Discounted NPA conference registration fees
  8. CMS-sponsored meetings
  9. Keeping the PACE newsletter
  10. Monthly Educational Teleconference Series

Looking Ahead: Enrollment and Ongoing Operations

After federal approval of the PACE provider application, the new PACE program, the state and the federal government sign a program agreement to establish the program's PACE provider status. At this point in the program's development, activities shift from planning to operations. NPA and the Technical Assistance Centers (TACs) continue to provide resources to support the success of new PACE programs as they move into this operational mode.

Early in the program's operations, the organization will need to focus on building its census. During this time it also is important to ensure that planned systems and procedures for establishing the interdisciplinary care team, integrating services and allocating resources are working effectively. Provider status also requires the establishment of quality improvement mechanisms and readiness for on-site reviews by state and federal agencies.

As the program matures, the PACE program continues to build upon and improve existing operations, increase census and consider plans for future expansion.

The Centers for Medicare and Medicaid Services (CMS) and the state will continue ongoing monitoring of the program. The PACE program will be responsible for meeting evolving state and federal regulatory requirements.

Resources available to start-up and operational PACE programs include:

  • Updated and expanded resources for PACE start-up and operations in the Core Resource Set for PACE (CRSP)
  • Performance benchmarking for service outcomes, utilization and costs
  • Networking list serves
  • Federal and state advocacy
  • Updates on federal and state policies
  • NPA communications
  • Discounted NPA conference registration fees
  • CMS-sponsored meetings
  • Keeping the PACE newsletter
  • Developing PACE Education Series
  • Monthly Educational Teleconference Series

The National PACE Association (NPA) exists to advance the efforts of Programs of All-inclusive Care for the Elderly (PACE). PACE programs coordinate and provide all needed preventive, primary, acute and long term care services so that older individuals can continue living in the community.

How NPA Supports PACE Programs
Public Policy and Advocacy
NPA works closely with members of Congress, senior administration officials and their staff, and state policy makers to educate and promote a reimbursement and regulatory environment that enables PACE programs to continue to provide high quality, individualized and innovative care.

Educational Opportunities
NPA hosts two conferences per year and a monthly teleconference series, so members can learn from one another and from leading experts in the long term care field.

Start-up and Operational Resources
NPA facilitates networking list serves for staff from various disciplines within PACE programs, and produces other communications vehicles to assist developing and operational programs.

NPA members have access to the Core Resource Set for PACE (CRSP), a compendium of resources for PACE program development, expansion and operations.

NPA members have access to financial planning tools, including the PACE Financial Proforma, a financial spreadsheet model for forecasting budgets and financial performance.

NPA hosts a quarterly teleconference series focused on issues faced by organizations contemplating and pursuing PACE development.

NPA provides guidance and support for a range of policy and operational issues and challenges.

Quality Assurance
NPA collects data from participating PACE programs to help them compare the provision of services and participant characteristics across PACE programs. This benchmarking data is helpful in allowing PACE program staff to continuously improve their delivery of services.

NPA is committed to supporting the study of innovative and integrated models of care with the goal of improving the lives of seniors and their families, regardless of the health care setting.


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