Integrating Care for Aging Populations: Dual‐Framework Policy Analysis of the United States Program of All‐Inclusive Care for the Elderly (PACE)

ABSTRACT

Aim

To critically analyse the federal Program of All-Inclusive Care for the Elderly (PACE) using the Integration Continuum Framework and the Conceptual Model for Nursing and Health Policy, identifying system-level strengths, equity gaps and nursing implications for long-term care reform.

Background

The U.S. long-term care system remains fragmented and institutionally biased, disproportionately affecting dual-eligible older adults who account for outsized healthcare expenditures despite comprising just 17% of Medicare beneficiaries. Permanently authorised under the Balanced Budget Act of 1997, PACE delivers fully integrated, community-based care for individuals aged 55 and older who qualify for nursing home-level services but prefer to remain in their communities.

Design

A policy analysis guided by dual conceptual frameworks assessing PACE structure, implementation and impact across four policy outcome levels: efficacy, effectiveness, equity and justice.

Methods

This policy analysis was conducted between May and July 2025. Two conceptual frameworks were applied to examine PACE structure, implementation and outcomes. Data sources included peer-reviewed studies, federal legislation, policy documents and grey literature published between 2020 and 2025, supplemented by international integrated care literature.

Findings

PACE demonstrates strong efficacy and effectiveness, with fully integrated interdisciplinary teams and reduced institutionalisation for enrolled older adults. However, the program falls short on equity and justice due to limited geographic reach, racial and ethnic disparities in enrollment, exclusion of Medicare-only populations and persistent nursing workforce challenges.

Conclusion

PACE exemplifies a high-functioning integrated model of community-based long-term care, but current policy constraints prevent it from achieving scale and equity. Without eligibility expansion, financing reform and workforce investment, its transformative potential will remain unrealised. Nurses are central to this vision and must be empowered as clinical leaders and policy advocates to sustain care coordination and advance health equity in aging populations.