Abstract
The Programs of All-Inclusive Care for the Elderly (PACE) model programs are in the forefront of redefining the delivery of long-term care to the frail elderly. The Elder Service Plan of Massachusetts (ESP) is one of several PACE sites providing comprehensive, cost-effective, community-based long- term care using a multidisciplinary team approach. A case study provides an example of how one participant on the verge of institutionalization is able to remain living in the community because of the flexibility that exists through the PACE model. ESP has maximized continuity of care through the role of a nurse practitioner, whose primary management areas are in the home and various skilled nursing facilities.
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