A national study of dental care delivery and utilization at programs of all-inclusive care for the elderly (PACE)

Matthew Masayoshi Oishi, University of Iowa


Background: The Program of All-inclusive Care for the Elderly (PACE) is a program of care that enrolls nursing home eligible and offers them community-based long-term services and supports (LTSS). Many PACE enrollees are “dual eligibles” (DEs) meaning they qualify for Medicare and Medicaid services. Dental care is a unique feature of PACE among LTSS, as many LTSS do not include dental care, even though this population has difficulty in accessing these services. However, little is known about the delivery of dental care at PACE and how dental care and oral health promotion and prevention is being integrated into PACE. Thus, the purpose of this study is to describe the delivery and integration of dental care at PACE.

Methods: Based on ten preliminary interviews and the PACE manual from the Centers for Medicare and Medicaid Services (CMS), a 56-question survey was developed to describe the delivery and integration of dental care at PACE across the country. In addition, the survey asked programs to rank their focus among five specialties (dentistry, mental health, optometry, audiology, podiatry), to determine if a program’s focus on dental care would influence the delivery and integration of dental services at PACE, and if this would lead the program to have a very high percentage of new and continuous enrollees with regular dental examinations. A publicly available contact list was obtained from CMS and the survey was distributed to all 124 PACE programs via email.

Results: Respondents in this study represented 35 programs (28.2%) in 23 states (74.2%). Most programs had no limits for dental care, minimal waitlists, and provide most dental services without exclusions. This is evident by the 51.4% of programs that have no dental budget, 100% of programs providing preventive and basic restorative dental care, and nearly 100% offering advanced restorative services. Many programs also did not have a waitlist for non-emergent dental care. Few programs include a dentist in the routine operations of the PACE program, as evidenced by few programs having dentists conduct the dental assessment for the initial comprehensive assessment or having a dental director.

A statistically significant association with a high percentage of reported utilization of dental examinations was detected with programs having a system for quality assurance for dental care (t=0.358, p=0.024), a protocol for a dental cleaning every 6-12 months (t=0.595, p

Conclusion: This study suggests that compared to nursing homes, PACE enrollees may have greater ability to receive dental care without limitations of the state adult Medicaid dental benefit. Dentistry also appears to be a high focus for some PACE programs. This study has begun to identify structures that support positive outcomes that can be used to develop best practices and guidelines for the delivery of dental care in PACE and other LTSS. Future studies are needed to better understand barriers and facilitators to the delivery of dental care and other specialty services.