A Framework for Behavioral Health Integration in the Program of All-Inclusive Care for the Elderly (PACE)

The Program of All-inclusive Care for the Elderly (PACE) is a comprehensive care model that aims to promote aging in the home and community for older adults who are nursing-home eligible needs-wise. Older adults experience age-related barriers to accessing behavioral health (BH) services. PACE programs play an important role in providing all-inclusive health care for individuals over 55 who are dually eligible for Medicaid and Medicare. This article investigates behavioral health integration (BHI) within PACE Organizations (POs), produces a conceptual framework for BHI within PACE, and reports on current BH practices and programmatic needs to support the growing BH needs of participants.

The team adapted the BH-Serious Illness Care (BH-SIC) Model, to produce a conceptual framework for BHI within PACE (BHI-PACE Model). The model informed a mixed-methods sequential approach to assess BHI at POs that include (i) a survey, (ii) use-case interviews of POs, and (iii) qualitative analyses of interviews.

We present the domains and subdomains for the BHI-PACE Model. With respect to the national BH in PACE assessment, 38 POs representing 119 sites and 25,806 participants participated in the survey and 15 POs representing 58 sites and 10,029 participants participated in interviews. Survey results revealed a high rate of BH comorbidities among PACE participants (60% median rate, IQR: 70-44). The most common reasons for referral to BH specialists were depression and mood disorders 92.1%, behavioral and psychological symptoms of dementia (BPSD) 57.9%, and anxiety disorders 55.3%.

POs' current BH practices and challenges can guide other POs to better integrate BH. Integrating BH into the PACE model requires policy-level action, though quality measurement and value-based care efforts can support this endeavor.