Rural communities across the country are aging at a faster rate than urban communities, with older adults in these regions experiencing higher rates of disability and chronic disease. These disparities are driven, in part, by limited access to primary and specialty care — creating a growing need for long-term services and supports. To address this need, comprehensive home- and community-based service models are essential. These models can help address critical gaps in rural health — such as limited transportation and the impact of nursing facility closures — while enabling older adults to age in place.

The Program of All-Inclusive Care for the Elderly (PACE) is a fully integrated, provider-led model serving adults 55 and older who qualify for nursing home-level care but prefer to receive that care in their homes and communities. PACE primarily serves individuals who are dually eligible for Medicare and Medicaid, allowing for the integration of services and funding across both programs. As of September 2025, PACE operates in 33 states and the District of Columbia, serving over 89,000 enrollees. Evaluations show that PACE may reduce costly hospitalizations and emergency department visits, while improving mental health outcomes, including reduced depression and social isolation. As states pursue initiatives like the Rural Health Transformation Program, PACE contributes valuable lessons in delivering integrated, community-based care.

PACE offers many positive outcomes, and evidence on its implementation and impact in rural communities is also positive, albeit limited. To explore this topic, CHCS spoke with Carrie Henning-Smith, PhD, MPH, MSW, associate professor at the University of Minnesota School of Public Health (UMN) and co-director of UMN’s Rural Health Research Center. Her insights shed light on PACE’s presence in rural communities and highlight both the strengths and challenges rural PACE organizations face in delivering care.

Q. How can PACE organizations support older adults in rural communities?

A. Most older adults, including rural older adults, would prefer to age in place — that means staying in their homes and communities as they grow older. But not all older adults have adequate support to help them do so, especially as they develop disabilities or functional limitations, or if they are low-income. PACE offers comprehensive long-term services and supports to older adults who qualify based on income and functional status, especially those who are dually eligible for Medicaid and Medicare. PACE fills gaps to help people who might otherwise require institutional long-term care. In rural places, that often means relocating to communities far from home, which is disruptive to individuals, families, and communities.

Q. Why is PACE so important today, specifically?

A. The idea for PACE is not new — it’s been around since 1971 in some form. But the need for PACE is increasingly urgent as our population ages, and the ratio of working adults or potential caregivers to older adults is not aligned. We need to be creative, resourceful, and innovative in thinking about how to serve folks who need long-term services and supports. States are grappling with the best ways to fund high-quality and cost-efficient care for older adults, especially those enrolled in Medicaid, which funds a majority of long-term care. PACE is a strong example of how states can take a creative and resourceful approach to meeting the needs of older adults with significant health and financial challenges — delivering comprehensive services directly in the communities where people live.

Q. What has your research found in terms of the extent of PACE in rural communities?

A. We did some quantitative analyses looking at differences between rural states with and without PACE, as well as enrollee characteristics between rural and urban PACE organizations. States without PACE have, on average, 39 percent of their population living in rural areas, compared to 23 percent in states with PACE. This tells us that some of the most rural states are not currently being served by PACE. We also found that rural communities with a PACE headquarters had more residents who identify as Hispanic, had higher educational attainment, but also higher unemployment, greater geographic mobility, and lower rates of homeownership. These demographic differences for rural counties that have PACE headquarters present opportunities and challenges for the populations that these organizations serve. Rural PACE organizations were serving fewer enrollees, which makes sense as they have a smaller population to draw from. Rural PACE organizations are also more likely to serve participants younger than 65 years old, representing a distinct portion of the older adult population.

Q. What are some of the strengths of PACE organizations serving rural communities?

A. In our interviews with 19 rural-serving PACE organizations, we heard strengths related to job opportunities, social connectedness, person-centered care, and enrollment. People really liked the PACE model of tailored and holistic care. People were also excited that PACE could create jobs for local residents and attract specialists and other providers to rural communities. We also heard a lot about the importance of social connectedness and the close-knit nature of many rural communities. Those relationships helped strengthen the PACE model by ensuring everyone receives person-centered care and no one is overlooked or falls through the cracks. These rural organizations also shared that their positive reputation contributed to PACE enrollment growth. While there may be a lag in people learning about PACE, enrollment improved once people learned about it and spread the word across the community.

Q. Can you share some of the challenges you found through your interviews with PACE organizations in rural communities?

A. We heard about several challenges they experience in serving their rural population. Transportation is one — they have limited vehicles yet serve a large geographic area. Staffing shortages can be more pronounced in rural areas, which makes staffing interdisciplinary care teams particularly difficult. Lastly, there is not a lot of public awareness of PACE. This may be related to some areas having lost their local newspaper, which impacts the ability to get the word out about available services.

Q. Did any findings in your research surprise you or challenge your assumptions about the PACE model?

A. I was really struck by the opportunity to grow PACE or similar models in rural areas. Nearly 20 states don’t offer PACE, including states with the largest rural populations. Our analyses show that rural areas with some of the greatest needs are not currently being served by PACE. However, our research didn’t examine whether those rural places are instead using other comprehensive long-term services and supports programs, so there’s more research needed.

Q. In implementing PACE in rural areas, what supports or partnerships are most needed?

A. The organizations we talked with considered their community partnerships critical. Local organizations, health care providers, and others were very supportive of the model and excited to have it available in their community. I think partnerships are one of the most exciting features of PACE due to the comprehensiveness and multidisciplinary team components of the model. Staffing an entire team, especially in areas that already have workforce shortages or fewer enrollees, can be challenging, especially when providing PACE over large, sparsely populated areas. But there are a number of potentially creative solutions to address transportation challenges, such as offering satellite sites or partnerships with other transportation providers.

Q. What are some key takeaways for policymakers in thinking about sustaining or growing PACE in rural communities?

A. It’s important for policymakers to recognize the value of programs like PACE, which provide cost-effective, high-quality services to older adults. We’re currently funneling a lot of Medicaid dollars to costly institutional care, while older adults prefer to remain in their homes and communities. Providing PACE or any other comprehensive long-term services and supports in rural areas comes with particular challenges in large, low-population density areas. In these areas, there is a greater need for flexibility in implementing the PACE model, as well as additional funding to initiate services, sustain operations, and support overhead costs.