A Team Built Around YOU!
When you join PACE, you get more than a medical provider — you gain an entire team of professionals who know you, your health, and your goals.
Our Interdisciplinary Care Team (IDT)
Our IDT works together to create an individualized care plan for you that supports every part of your well-being – from medical needs to daily living.
ESP’s goal is to help you live a healthy and independent life in your community. Your IDT is made of 11 professionals who will assess your needs and create a care plan just for you. They will provide the services they order for you in your home, at one of our PACE centers, or at a provider’s office in our network.
Talk with us about Elder Service Plan!
Your primary care provider delivers comprehensive medical care, manages chronic conditions, coordinates with specialists, and oversees the participant’s overall health plan. Conducts regular assessments and adjusts treatment plans as needed.
Our Occupational Therapist, Recreational Therapist, Physical Therapist evaluates functional abilities, develops therapy plans to maintain or improve mobility and independence, provides adaptive equipment, and creates safe home environments to prevent falls and injuries.
Our home Health Aide, Home Care Manager arranges and oversees personal care services, coordinates with Home Health Aides, ensures safe home environments, and manages the delivery of durable medical equipment and supplies.
Your Home Care Nurse monitors health status, administers medications, provides health education, and coordinates care between team members. Serves as a key liaison for participants and families regarding health concerns.
Your Social Worker assesses psychosocial needs, provides counseling and support, connects participants with community resources, and helps navigate complex healthcare and social systems. Advocates for participant rights and preferences.
Our dietitian assesses nutritional status, develops meal plans for chronic conditions, provides nutrition education, and ensures participants receive appropriate dietary support including therapeutic diets when needed.
Our PACE Center Supervisor develops and implements recreational and therapeutic activities, promotes social engagement, organizes group programs, and creates opportunities for meaningful participation in the PACE community.
Our Transportation Coordinator arranges medical and non-medical transportation, ensures participants can access PACE center activities and appointments, and coordinates specialized transport for mobility-impaired participants.
Your Care Coordinator all IDT members to deliver medical and non-medical care services and ensures participants can access PACE center activities and appointments.
To speak with us directly, call:
For text telephone assistance, please use our TTY line:
Harbor Health Elder Service Plan (ESP) will be your sole provider for primary care and specialty care (other than emergency services). Care is provided directly by ESP or a provider we approve. ESP participants may be fully and personally liable for the costs of unauthorized or out-of-ESP program services. H2218_Web_11-5-2025 Pending CMS review.
- Last Updated: