ElderONE and PACE in Rochester: How It Works and Who It Fits

What PACE is

The Program of All-Inclusive Care for the Elderly is a Medicare and Medicaid model in which one organization takes responsibility for all of a participant's care: primary care, specialists, prescriptions, therapy, home care, transportation, day center attendance and, when needed, hospital and nursing home care. A team of doctors, nurses, therapists, social workers and aides meets regularly about each participant. In New York, PACE is one of the Managed Long Term Care models.

ElderONE in Rochester

ElderONE, an affiliate of Rochester Regional Health, describes itself as the only PACE program in the greater Rochester area and serves Monroe, Ontario and Wayne counties through day centers. To join, a person must be 55 or older, live in the service area, need community-based long-term care for more than 120 days, and be able to live safely in the community with PACE support. The state roster also lists ElderONE as a licensed home care services agency at several Rochester-area addresses.

PACE versus a regular Managed Long Term Care plan

The biggest difference is the doctor. PACE participants receive primary care from the PACE team, which some families find reassuring and others find hard after years with a trusted physician.

Who PACE fits best

PACE tends to fit someone with several chronic conditions, a family caregiver who works or needs relief, and a preference for staying at home. The day center gives structure and company, transportation is included, and the team catches problems early. It fits less well for someone who wants to keep their own specialists or who already lives in a residence that is not part of the PACE network.

A week in PACE

A typical participant might spend two or three days a week at a PACE day center, arriving by PACE transportation in the morning. The day can include a check by the nurse, physical therapy, lunch, activities, a shower with help if needed, and a visit with the PACE physician when something changes. On the other days, PACE aides may come to the home for personal care. Prescriptions are filled through PACE, and specialist visits are arranged and transported by the team.

When something goes wrong, the family calls the PACE team rather than a dozen separate offices. That single point of contact is what many caregivers value most. The trade-off is that the participant agrees to receive care through PACE's network, including for hospital and nursing home care when needed, except in emergencies.

Families sometimes worry that a day center means a loss of independence. In practice, participants choose how often they attend, and many describe the center as the social anchor of their week, especially through the winter. Caregivers, for their part, gain predictable hours to work or rest, which is often what keeps care at home sustainable.

Questions to ask before enrolling

Ask which day center the participant would attend and how long the ride is. Ask how the PACE physician coordinates with specialists the participant already sees, and which hospital PACE uses for admissions. Ask what home care hours the team typically provides for someone at your parent's level of need, and how quickly they can increase hours after a hospital stay.

Ask also what happens if the participant later needs to live in a residence or nursing home, which facilities PACE works with, and how room and board is handled there. Finally, ask how to leave PACE if it is not a good fit, and how long it takes to restore regular Medicare and Medicaid coverage. A good program answers all of these plainly.

If your parent lives in Livingston or Orleans County, PACE is not available, and the closest equivalent is a Managed Long Term Care plan combined with an adult day program and the county Office for the Aging's services.

How to start

Call ElderONE directly, or NY Connects at (585) 325-2800 for Monroe County. Expect a home visit and an assessment. People with Medicaid pay no premium; people with Medicare only can join and pay a monthly premium for the Medicaid portion. Enrollment is voluntary and a participant can leave.