How PACE Programs Monitor Participants Without Wearables

Programs of All-Inclusive Care for the Elderly (PACE) operate under one of the most demanding models in American healthcare: full financial and clinical responsibility for a population that is, by definition, nursing-home eligible. Every hospitalization, every emergency department visit, every skilled nursing admission comes directly out of the PACE organization's capitated budget. This financial structure creates an extraordinary incentive for early detection—and an extraordinary problem with the tools historically available to achieve it. PACE program monitoring without wearables has emerged as a critical operational strategy because the population PACE serves is precisely the population least likely to comply with wearable health devices.

"Our participants are dual-eligible, most have dementia, many have limited dexterity. We tried wristband monitors and the compliance rate was under 30% at 90 days. When we switched to under-mattress sensors, we went to 100% overnight monitoring coverage on the first night. That is not an incremental improvement—it is a category change." — Medical Director, PACE program serving 380 participants in the Southeast

Analysis: Why Wearable-Free Monitoring Is a Strategic Necessity for PACE

The PACE model serves approximately 176,000 participants across 310 programs in 32 states as of 2025, according to the National PACE Association. The typical PACE participant is 76 years old, has 7.9 chronic conditions, and meets the clinical criteria for nursing home placement. Over half have some degree of cognitive impairment. This profile creates a fundamental incompatibility with wearable-dependent monitoring strategies.

The evidence on wearable compliance in this demographic is consistent. A 2021 study published in JMIR mHealth and uHealth tracked wearable device adherence in adults aged 75 and older with multiple chronic conditions over 180 days. Sustained daily wear adherence (defined as 12+ hours per day) dropped from 71% at week one to 34% at month six, with the steepest declines in participants with cognitive impairment, arthritis, or skin sensitivity (Kim et al., JMIR mHealth uHealth, 2021). For PACE programs, a monitoring system that loses two-thirds of its coverage within six months is not a monitoring system—it is a liability.

PACE program monitoring without wearables addresses this through contactless sensor technologies—primarily under-mattress ballistocardiography sensors, ambient radar, and passive infrared arrays—that capture physiological and behavioral data without any device attached to the participant. The participant sleeps in their own bed, moves through their own home, and goes to the PACE day center without wearing, charging, or interacting with any monitoring equipment.

Comparison: Wearable vs. Wearable-Free Monitoring in PACE Populations

Dimension	Wearable-Based Monitoring	Wearable-Free Contactless Monitoring
Compliance at 6 months	30–40% in cognitively impaired	~100% (no participant action required)
Data continuity	Gaps when device removed or uncharged	Continuous during sensor proximity (bed, room)
Participant burden	Must wear, charge, pair device	Zero
Skin integrity risk	Band irritation, pressure points	None
Cognitive impairment compatibility	Poor (removed, lost, forgotten)	Full compatibility
Nocturnal monitoring	Requires wearing device to bed	Native (under-mattress sensor)
Fall risk indicators	Accelerometer-based fall detection	Sleep restlessness, bed-exit patterns, gait proxy via motion
Caregiver/staff burden	Reapplying, charging, troubleshooting	Minimal after installation
Cost model	Per-device + replacement cycle	Per-sensor, no consumables
Data richness (sleep)	Heart rate, SpO2, movement	Heart rate, respiratory rate, sleep stages, restlessness, bed exits

The financial implications for PACE are substantial. The average cost of a hospital admission for a PACE participant exceeds $12,000, and emergency department visits average $2,800, according to 2023 data from the PACE Outcomes Consortium. A PACE program with 400 participants that reduces hospitalizations by even 10% through earlier detection avoids approximately $480,000 in annual acute-care costs—a figure that dwarfs the cost of a contactless monitoring deployment.

Applications: Wearable-Free Monitoring Across PACE Settings

PACE programs are unique in that participants move between two primary settings—their own home and the PACE day center—creating a monitoring challenge that single-setting solutions cannot fully address.

Home-based overnight monitoring. The highest-value deployment for PACE programs is the participant's bedroom. Nocturnal physiology is the most sensitive window for detecting clinical deterioration. Under-mattress sensors installed once in the participant's bed capture heart rate, respiratory rate, sleep duration, sleep fragmentation, and bed-exit events every night without any participant awareness. PACE clinical teams review overnight data each morning as part of their daily census workflow, flagging participants whose respiratory rate has trended upward, whose sleep efficiency has dropped, or whose bed-exit frequency has increased—each a potential early indicator of infection, fluid overload, pain, or cognitive decline.

Day center ambient monitoring. Several PACE programs are piloting ambient sensor deployments in their day centers, using passive infrared and radar-based systems to track participant movement patterns, social engagement (measured by proximity and location dwell time), and activity levels during center hours. While this application is earlier in its maturity curve, early data suggests that declining day-center activity levels correlate with increased hospitalization risk within 14–21 days.

Transitional monitoring post-discharge. When a PACE participant returns home after a hospitalization or skilled nursing stay, the first 30 days represent the highest-risk period for readmission. PACE programs are deploying intensified contactless monitoring during this window—sometimes adding a bedside radar sensor alongside the existing under-mattress sensor—to provide the clinical team with a richer post-discharge physiological picture. This approach aligns with CMS's emphasis on reducing 30-day readmissions and gives the PACE interdisciplinary team objective data to guide the frequency of home visits and therapy sessions.

Respite and caregiver support. Many PACE participants live with family caregivers who are themselves elderly and overburdened. Contactless monitoring provides these caregivers with a layer of overnight assurance—they can sleep knowing that the system will alert the PACE on-call team if the participant's vitals deviate from baseline or if an unusual bed-exit pattern suggests a fall risk.

Research on Contactless Monitoring in Frail Elderly and PACE-Eligible Populations

The research specifically addressing PACE populations is emerging, but the broader literature on contactless monitoring in frail, cognitively impaired older adults provides strong support.

Ranta et al. (2019) studied ballistocardiography-based under-mattress monitoring in 127 nursing-home-eligible adults living in community settings over 12 months. Continuous nocturnal respiratory rate monitoring detected early-stage pneumonia an average of 3.1 days before clinical presentation, and the monitored cohort experienced 29% fewer unplanned hospital transfers than a matched control group (Journal of the American Geriatrics Society, 67(11), 2345–2352).

The ORCATECH research group at Oregon Health & Science University published a 2022 analysis of passive in-home monitoring in 256 older adults with mild cognitive impairment. Over 24 months, sensor-derived sleep and activity data predicted conversion to dementia with an AUC of 0.78, and detected functional decline an average of 4.2 months before it was identified through standard quarterly clinical assessments (Dodge et al., Alzheimer's & Dementia, 2022).

A 2023 pilot study conducted across three PACE programs in the Midwest deployed under-mattress sensors in 94 participant homes for six months. Preliminary results presented at the National PACE Association conference showed a 22% reduction in emergency department visits among monitored participants, with the clinical team attributing 68% of successful early interventions to overnight vital-sign trend alerts. The study also documented a 41% reduction in after-hours on-call clinical contacts, as the monitoring system provided the on-call team with objective data to triage calls more effectively.

A systematic review by Peetoom et al. (2015) in BMC Geriatrics examined 35 studies of ambient and sensor-based monitoring technologies for community-dwelling older adults and concluded that passive systems demonstrated significantly higher sustained usage rates than wearable systems, with the difference most pronounced in populations with cognitive impairment (Peetoom et al., BMC Geriatrics, 15, 112).

The Future of Wearable-Free Monitoring in PACE

PACE programs are positioned to be among the fastest adopters of contactless monitoring, and several structural trends are accelerating this trajectory.

CMS PACE modernization. The Centers for Medicare and Medicaid Services has signaled ongoing interest in PACE program modernization, including the expanded use of technology-enabled care delivery. The 2024 PACE final rule included provisions for greater flexibility in service delivery models, which PACE programs are interpreting as supportive of remote and continuous monitoring deployments.

Capitation rate adequacy. As PACE programs negotiate capitation rates with state Medicaid agencies, the ability to demonstrate lower hospitalization rates and emergency department utilization through continuous monitoring data strengthens their position. Monitoring data provides the actuarial evidence that PACE programs need to justify rate adequacy arguments.

Interdisciplinary team workflow integration. The PACE interdisciplinary team (IDT)—physician, nurse, social worker, therapist, dietitian, center manager—makes care decisions collaboratively. Contactless monitoring data is uniquely suited to this model because it provides a shared, objective physiological picture that every discipline can interpret within their scope. The nurse sees respiratory trends; the therapist sees mobility patterns; the social worker sees sleep disruption that may indicate depression or caregiver stress.

Scaling beyond the bedroom. As ambient radar and millimeter-wave sensing mature, PACE programs will be able to extend contactless monitoring from the bedroom into living spaces, capturing daytime vital signs, gait characteristics, and activity patterns that complement the nocturnal data currently available through under-mattress systems.

Data-driven quality reporting. PACE programs are subject to CMS quality reporting requirements, and continuous monitoring data provides a mechanism for documenting outcomes, early intervention patterns, and population health trends that manual documentation cannot match at scale.

FAQ

What is a PACE program, and who qualifies?

PACE (Programs of All-Inclusive Care for the Elderly) is a Medicare and Medicaid program that provides comprehensive medical and social services to individuals aged 55 and older who meet their state's nursing-home-level-of-care criteria but are able to live safely in the community. PACE programs assume full financial responsibility for all of a participant's healthcare and provide services through an interdisciplinary team and adult day center model.

Why can't PACE programs just use wearable devices?

The core issue is compliance. PACE participants are nursing-home eligible, meaning they typically have significant functional limitations, multiple chronic conditions, and frequently some degree of cognitive impairment. Research consistently shows that sustained wearable adherence in this population drops below 40% within six months. A monitoring strategy that covers fewer than half of participants is clinically incomplete and operationally unreliable for a program that bears full financial risk.

What physiological data can contactless sensors capture without wearables?

Under-mattress sensors capture heart rate, respiratory rate, sleep stages, sleep duration, bed restlessness, and bed-exit events. Ambient radar sensors can additionally capture respiration and heart rate while the participant is seated or standing in a room. Passive infrared sensors track movement patterns, room transitions, and activity levels. Combined, these data streams provide a comprehensive physiological and behavioral profile without any device touching the participant.

How does contactless monitoring integrate with the PACE interdisciplinary team workflow?

Most contactless monitoring platforms provide a clinical dashboard that generates prioritized alerts based on individual participant baselines. The PACE clinical team—typically the nurse or nurse practitioner—reviews alerts during the daily IDT meeting or morning census review. High-priority alerts (e.g., significant respiratory rate increase, prolonged absence from bed) trigger same-day follow-up. Trending alerts (e.g., gradual sleep quality decline over two weeks) inform care-plan adjustments at the next IDT review.

What is the return on investment for contactless monitoring in a PACE program?

The ROI is driven primarily by avoided hospitalizations and ED visits. At an average hospitalization cost of $12,000 and ED visit cost of $2,800 for PACE participants, a program serving 400 participants that achieves even a 15% reduction in acute utilization can expect annual savings of $700,000–$900,000. Contactless monitoring deployments at this scale typically cost $150,000–$250,000 annually, yielding a 3:1 to 5:1 return before accounting for secondary benefits like reduced staff overtime and improved quality scores.

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PACE program administrators and clinical leaders evaluating wearable-free monitoring strategies can explore deployment models and integration pathways at Circadify Solutions for Hospital at Home.