Partner with Harbor Health's Elder Service Plan to Support Older Adults with Complex Needs
Harbor Health’s Elder Service Plan (ESP) is a Program of All-Inclusive Care for the Elderly (PACE). Our PACE plan offers an evidence-based, team-driven model of care that supports medically complex older adults to remain safely in the community, reducing hospitalizations, improving adherence, and enhancing overall quality of life.
As a referring provider, you can be confident your patients will receive comprehensive, coordinated, and compassionate care that aligns with their goals and clinical needs.
We follow the Patient Priorities Care Model
and focus on what matters most to each participant.
As a non-profit healthcare organization with more than 30 years of experience, Harbor Health’s Elder Service Plan specializes in serving older adults with complex medical and social needs in our service areas.
Our interdisciplinary team works closely with each participant to deliver comprehensive, integrated care, recognizing that many older adults are best supported outside of institutional settings.
Need more information about our services? Click below to learn more.
Key Benefits for Your Patients
Integrated, comprehensive care
All medical, behavioral health, social, and supportive services are delivered through a single, cohesive system—minimizing fragmentation and improving continuity of care.
Interdisciplinary team approach
Each participant is supported by a dedicated team of healthcare professionals, including physicians, nurses, social workers, dietitians, therapists, and others, ensuring personalized and coordinated treatment plans.
Home-based and community-focused
Care is delivered wherever it’s needed, at home, in our ESP Day Center, or in the community, helping patients maintain independence and avoid unnecessary institutional care.
Medication management
Harbor Health’s PACE plan ensures accurate, safe, and monitored medication use, reducing adverse events and improving adherence.
Day center services
Participants have access to on-site medical care, rehabilitative therapies, meals, social activities, and supervision, all designed to promote physical, cognitive, and emotional well-being.
Social engagement and emotional supprot
Structured programming and peer connection combat isolation and contribute to better mental health outcomes.
Transportation and caregiver support
Safe, reliable transportation to medical appointments and day center services is provided, along with education and respite support for caregivers.
Responsive, evolving care plans
Care plans are continuously adapted to meet changing medical and functional needs, ensuring timely interventions and improved outcomes.
Introducing PACE as an option
Sometimes older adults can understandably feel unsure about making changes to their healthcare providers. To help you start the conversation with your patients, Harbor Health’s Elder Service Plan has three ideas for talking about PACE as a care option. Click the button to download our conversation guide.
Elder Service Plan Referral Form
Harbor Health’s 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_09-25-2025 Pending CMS review.