GrantWatch Blog asked Tina Markanda, a program officer at the Duke Endowment, to write about a recent webinar.

The massive growth of the age sixty-five-plus population in the United States will bring new challenges and opportunities as that “silver tsunami” fast approaches. This topic—and programs to meet needs for this population—were recently discussed by a group of Southeastern Council on Foundations colleagues participating in the EngAGEment Initiative, a project funded by Grantmakers In Aging and the Atlantic Philanthropies to increase knowledge about grant making for elders.

The discussion included the perspective of Marianne Ratcliffe, executive director of the Program of All-Inclusive Care for the Elderly (PACE) site in Burlington, North Carolina, regarding that program’s experiences. Also, as a program officer in health care at the Duke Endowment, I spoke about the endowment’s experiences with PACE, an evidence-based model of care for the frail elderly.

First, a bit of background: PACE is based on a system of care developed more than three decades ago by On Lok Senior Services, in San Francisco. The Health Care Financing Administration (now Centers for Medicare and Medicaid Services) tested the PACE model through demonstration projects that began in the mid-1980s. Funders including the Robert Wood Johnson Foundation and the John A. Hartford Foundation played important roles in refining the model and assisting in its expansion nationally. PACE is still relatively new to North Carolina and South Carolina, the two states in which the Duke Endowment funds.

PACE is a community-based program that serves as an alternative to traditional institutional care. It has consistently demonstrated positive clinical outcomes and increased client and family satisfaction at reduced costs. Research studies have documented the impact of PACE.

Most importantly, the program allows people to remain in the community and receive all of the benefits needed to “age in place.” PACE is a capitated program, which provides people with multidisciplinary medical and support services to meet their specific needs. Given the current supply and demand issues for existing resources to serve elders, community-based programs will be increasingly important.

To date, the Duke Endowment has funded three PACE sites (in North Carolina and South Carolina)—one in an urban area and two in rural communities. The sites are still in early stages of implementation and are achieving important outcomes. For example, at the Burlington PACE site, in its first two years of operation, out of a total seventy-six participants, there have been only twenty-three emergency department visits, twenty-four hospitalizations, and no hospital readmissions. Given the frailty of PACE participants, these results are impressive. (According to the New England Journal of Medicine, approximately 20 percent of Medicare beneficiaries are readmitted to the hospital within thirty days.) With the assistance of the National PACE Association, to which all sites submit operational and cost data, the endowment will continue to monitor the experiences of the three currently funded sites as well as any sites funded in the future. The Kate B. Reynolds Charitable Trust has been a funding partner for the two North Carolina PACE sites.

During the Southeastern Council on Foundations webinar in late April, participants discussed the unique needs and challenges of operating PACE in rural communities. Issues such as transportation and the value of developing contracts with specialty providers have proven to be especially important for rural communities in serving elders comprehensively. A Centers for Medicare and Medicaid Services report on the expansion of PACE into rural areas was presented to Congress in early 2011.

In addition, the webinar participants reinforced the importance of community-based programs, particularly in light of the growing population of elders and the increasing desire of elders to remain at home.

PACE contains numerous elements that make this model worthy of consideration for foundation support: it is evidence based, comprehensive and multidisciplinary, financially sustainable (only one PACE program in the nation has ever closed), and community based. PACE emulates key tenets of health care reform and operates essentially as a mini-accountable care organization because it manages revenues and expenses to care for a specific population.

Resources to learn more about PACE are available at the National PACE Association. Conversations such as this one, which the Southeastern Council planned, are important to help grantmakers develop effective strategies and programs. I hope that it will trigger further discussions on this important issue.

To listen to the webinar, go to