Becoming a Patient, Eligibility, Enrollment, and Services

Caregivers should carefully evaluate the services, benefits, and eligibility criteria of Harbor PACE to determine if it aligns with their goals and needs of their loved ones. Applicants should be comfortable moving their primary care to our Harbor Health PACE Team.

You may qualify for Harbor Health PACE if you are: 

  • Living in or moving to our service area. (See service area map below).
    For a listing of zip codes, please click here.

     

  • Certified as needing nursing home level of care by State of Massachusetts. Harbor Health PACE will conduct the assessment on your behalf to determine eligibility.

     

  • Applicants must be able to live safely in the community with PACE services and resources.

     

  • Participants and their legal representatives (if applicable) need to agree to receive all necessary healthcare services, except in emergencies or when prior authorized by Harbor PACE, exclusively through the program.

     

  • Voluntary Participation: Participation in Harbor Health PACE is voluntary. Individuals can choose to enroll or disenroll at any time. 
locations

SERVICE AREAS

referral form

REFERRAL FORM

zip code listing

LISTINGS BY ZIP CODE

Not sure if you qualify? Click below to contact Harbor PACE.

Contact Harbor PACE

Becoming a Patient

Caregivers should carefully evaluate the services, benefits, and eligibility criteria of Harbor PACE to determine if it aligns with their goals and needs of their loved ones. Applicants should be comfortable moving their primary care to our Harbor Health PACE Team.

Here is a general outline of the steps involved in enrolling in PACE, for process specifics please contact the Harbor PACE Marketing Department at 617-533-2400.

  • Check Eligibility: Contact Harbor PACE to determine if you or your loved one meet the eligibility criteria for PACE. The Harbor Health team member will discuss with you your age, home address, medical, and insurance status. Most applicants qualify for both Medicare and Medicaid or are eligible for Medicaid only. Harbor Health PACE can also be privately funded by the participant.

  • Initial Assessment: The Harbor Health PACE program will conduct an initial assessment to determine if you meet the nursing home level of care requirement and are therefore medically eligible for the program. This assessment will involve evaluating the person’s medical, functional, and social needs and is conducted in the applicants home by a PACE clinician. Occasionally additional assessments may be required to determine safety in the community or the initial service plan.

  • Medicaid and Medicare Enrollment: If the individual meets the eligibility criteria and is clinically approved for the program the Harbor Health PACE Team will assist with the completion of the enrollment process.  We will assist with the Medicaid application and enrollment process.  This is crucial as most Harbor Health PACE participants are enrolled in Medicaid and Medicare.

  • Enrollment Approval: When an individual is clinically approved by the Harbor Health PACE Team and Medicaid and the necessary paperwork is completed the applications will be reviewed and the enrollment approved. The individual will then become an official participant in the program at the enrollment date.

  • Initial Service Plan: Harbor Health PACE will provide the applicant with an initial service plan. The plan is developed with input from the applicant, caregivers, and the Harbor Health PACE Team.  This plan will be reviewed during the initial care plan meeting held in the first month of enrollment.

  • Start of Services: After enrollment, which occurs on the first day of the month after approval and completing the enrollment paperwork, Harbor Health PACE will begin providing comprehensive healthcare services according to the personalized care plan. This may include medical care, social activities, therapy, prescription medications, and more.

  • Ongoing Assessment and Care: Harbor PACE will continuously monitor the individual’s health and adjust the care plan as needed to ensure their changing needs are met effectively.

Services

Harbor Health PACE is designed to provide coordinated and integrated care, including medical care, social services, and long-term care services, to help older adults continue living in their homes or communities rather than in nursing homes. PACE is funded through a combination of Medicare, Medicaid, and sometimes private funds. It is a unique model that focuses on providing holistic care to older individuals with complex medical and social needs.

For a complete overview of all Harbor PACE services, click here to see the enrollment agreement.

Except for emergency care, once someone is enrolled in PACE, all the care they receive must be approved by their Interdisciplinary Team. If the participant receives care that is not approved by the Interdisciplinary Team, they may be held financially responsible for services.The services offered by Harbor PACE are designed to address the unique needs of each participant and provide an integrated approach to care. 

Here are some of the specific services we provide:

  • Primary Medical Care: Harbor Health PACE participants receive primary medical care from a team of healthcare professionals, including doctors, nurses, and other medical specialists. This includes preventive care, treatment for acute illnesses, and management of chronic conditions.

  • Prescription Medications: Harbor Health PACE covers prescription medications as part of our services. Medication management and coordination are also provided to ensure that participants take their medications correctly.

  • Rehabilitation Services: A range of rehabilitation services, including physical therapy, occupational therapy, and speech therapy, as needed by participants.

  • Dental and Vision Care: Dental and vision care services, which can include routine check-ups, cleanings, and treatments.

  • Mental Health Services: Mental health servcies including counseling, therapy, and psychiatric services.

  • Social Services: Social workers and care coordinators assist participants with a variety of social needs, such as transportation, scheduling, and support for caregivers.

  • Nutritional Services: Nutritional assessments, dietary planning, and meal services, which can include meals both at the Harbor PACE center and at home.

  • Personal Care Services: Personal care assistance, such as help with bathing, dressing, and grooming, may be provided to participants who need these services.

  • Hospital and Nursing Home Care: Harbor PACE coordinates hospital and nursing home care for participants when needed and ensure a smooth transition back to the community.

  • Transportation: Available to and from the PACE center and for medical appointments.

  • End-of-Life Care: Harbor PACE offers palliative care and hospice services to provide comfort and support during the end-of-life phase.