Program of All-Inclusive Care for the Elderly

A nationally recognized integrated care model for dual-eligible seniors — individuals enrolled in both Medicare and Medicaid — that provides comprehensive, team-based medical, social, and long-term care services with the goal of enabling participants to remain in their homes and communities rather than entering nursing facilities. PACE programs operate adult day health centers as their primary service delivery hub, supplemented by in-home care, specialist referrals, and hospital services as needed. Interdisciplinary care teams including physicians, nurses, social workers, therapists, and dietitians coordinate all aspects of a participant's care under a capitated payment model that integrates Medicare and Medicaid funding into a single per-member-per-month payment. Oklahoma currently has three PACE programs serving approximately 800 members statewide, with one rural-based option. The RHTP allocates $15.2 million to launch three to six additional rural PACE centers, with telehealth and mobile clinic components built into the expansion model.

PACE is one of the few existing care models that fully integrates Medicare and Medicaid financing, making it a proving ground for the value-based care principles that national health infrastructure strategy is working to scale broadly. Its expansion into rural areas is a priority in both CMS's Innovation Center portfolio and Oklahoma's RHTP Shifting to Value pillar, because PACE has a demonstrated track record of reducing nursing home utilization and lowering total care costs for the highest-need, highest-cost population in the healthcare system. The model's telehealth extension — equipping PACE participants to receive care remotely between center visits — is an explicit component of Oklahoma's rural expansion design, and it creates a direct use case for Ready.net's Portal infrastructure. Rural seniors who cannot reliably travel to a PACE center, or who live in a county where no center yet exists, can use a library-based Portal for telehealth consultations with their PACE interdisciplinary team. As rural PACE centers scale nationally, they represent both a procurement partner and a clinical anchor for Portal network deployment — providing the credentialed care teams that Portal users need on the other end of the connection.