Programming a PACE Center From the Care Model Out
A PACE center is not a medical office building with exam rooms. It is an adult day health center, a clinic, a rehab gym, and a transportation hub under one roof, serving a frail elderly population with a van fleet arriving all day. That means large open program space, a commercial kitchen, heavy site circulation for van loading, real back-of-house for a large interdisciplinary staff, higher life-safety requirements, and a long licensing runway. Program the building from the care model, and pick a site that can move vans, or the real estate will fight the program for years.
PACE keeps frail, nursing-home-eligible seniors living in the community by wrapping all of their care into one program and, usually, one building. It is one of the most mission-aligned models in healthcare, and one of the most misunderstood on the real estate side. Teams that have built medical office space walk into a PACE project expecting exam rooms and hallways, and quickly find they are designing something closer to a community center with a clinic inside it.
Why can't a PACE program use a standard medical office?
Because the building has to do far more than deliver clinical visits. A PACE center is where participants spend the day, eat their meals, get their therapy, see their providers, and socialize, then ride home. A medical office building is exam-room-dense and small-suite efficient. A PACE center is the opposite: open, communal, and built around the flow of people who arrive and leave by van.
An MOB is designed for throughput. A PACE center is designed for a day. The participant is on site for hours, not minutes, and the building has to hold, feed, move, and care for them the whole time.
What does a PACE center need in a building?
The program drives an unusual mix of spaces that rarely coexist in one healthcare facility.
What the program demands
- Large adult day health space. Open activity and dining areas sized to a per-participant minimum set by state licensing, not a count of exam rooms. This is the heart of the building.
- A clinic within the center. Primary care, exam and treatment rooms, often behavioral health and dental, all integrated rather than in a separate suite.
- A rehab gym for physical and occupational therapy, with the floor space and equipment clearances that implies.
- A commercial kitchen to prepare meals on site, which brings its own MEP, ventilation, and health-department requirements.
- A transportation hub. A fleet of vans arrives and departs all day, so you need covered drop-off, accessible boarding, staging, and fleet parking, plus room for the circulation itself.
- Real back-of-house for the staff. A large interdisciplinary team works here all day, so they need functional workstations, a team room, a real break space to decompress, and staff parking that isn't an afterthought. More on this below.
Put those together and a PACE center often lands in the range of tens of thousands of square feet, with a site big enough to move vans. That combination is hard to find in a dense urban core, which is why so many PACE projects become second-generation big-box conversions or ground-up builds.
Why is the site harder than the building?
The building program is demanding, but the site constraints are what eliminate most candidates. Vans change everything.
A PACE fleet needs to pull in, board participants safely, including wheelchair lifts and mobility assistance, and pull out, many times a day, without gridlocking the lot or the street. That requires drive aisles, a covered sallyport or drop-off, staging space, and fleet parking on top of staff and visitor parking. A great building on a site that can't move vans is not a PACE center. It is a renovation you will regret.
Location has to thread a needle: close to the eligible senior population and their neighborhoods, reachable by the fleet, and on a parcel large enough for the footprint and the circulation. Those requirements pull in opposite directions, which is a big part of why PACE site selection takes as long as it does.
Why does staffing shape the building as much as the participants?
PACE is a staffing-heavy model. An interdisciplinary team runs the center all day: physicians, nurses, therapists, social workers, aides, drivers, dietary, and activities staff, all on site, all at once. The building has to hold and support that team as deliberately as it holds the participants.
And this is some of the hardest work in healthcare. The team cares for frail, elderly participants, many living with dementia, at the end of long lives that often lacked good care or steady support. It is physically and emotionally demanding, and it is that way every single day. There is also a quieter reward in it that the people who do this work will recognize: for many participants, this is the first care team that has ever been truly invested in them, the first real access to good care and social connection they have had. That is what makes the work meaningful, and it is also what makes it heavy.
Staff turnover is one of the biggest risks to a PACE program, and the building is one of the few burnout levers you control. A floor plan that fights the team all day is a floor plan that costs you people.
So the back-of-house cannot be an afterthought carved out of leftover square footage. It needs staff workstations that function, an interdisciplinary team room where the group can coordinate a participant's care, and a break room that is a genuine place to decompress rather than a closet with a microwave. Circulation matters just as much: staff should be able to move through the building and reach participants without fighting the layout on every trip. And staff parking has to be planned alongside the van fleet and participant drop-off, not squeezed in after, or your team is circling for a space before a shift that will already take everything they have.
Design the building to make hard work a little easier, and you keep the team that makes the model work. That retention is not a soft benefit. It is continuity of care for a fragile population and it is the difference between a program that runs and one that churns.
Why does the timeline run so long?
PACE sits at the intersection of real estate and heavy regulation, and both clocks run at once. You are pursuing state licensing for adult day health and the PACE program, CMS program approval, and a build that has to pass life-safety review for a non-ambulatory, medically frail population, which is a higher bar than a standard clinic. Stack those on top of finding a rare site and completing a large build, and the runway is long enough that PACE belongs in the category of projects where, as I have written, if you want to open in 2028 you start now.
The big-box that became a day center
A PACE operator I worked with evaluated a large second-generation retail box, on the order of 25,000 square feet, to convert into a center. On paper the square footage was ideal. The real work was everything the retail shell never had to consider.
The open floor became adult day and dining. A clinic, a rehab gym, and behavioral space had to be carved in without losing the communal core. A commercial kitchen meant new ventilation and utilities. And the parking field had to be re-planned entirely for van circulation and covered boarding, which drove as many design decisions as the interior did.
What made it work:
- Programming the building from the care model first, then testing the shell against it
- Solving van circulation and the kitchen early, because they constrained everything else
- Sequencing the licensing runway alongside the build instead of after it
How do you approach a PACE real estate project?
Start from the care model and the participant's day, not from available square footage. Program the building, then hunt for the rare site that can hold the footprint and move the vans. Solve the kitchen and the transportation hub early, because they constrain the rest of the design. Give the staff real back-of-house and parking, because the team is what the model runs on. And put the licensing runway on the schedule from day one, running in parallel with the real estate, not waiting behind it.
Key takeaways
- A PACE center is an adult day health center, a clinic, a rehab gym, a kitchen, and a transportation hub in one building, not a medical office.
- The program demands large open day space sized per participant, an integrated clinic and rehab, a commercial kitchen, and van infrastructure, so centers often run tens of thousands of square feet.
- The site is harder than the building: a van fleet needs covered boarding, staging, circulation, and fleet parking, which eliminates most dense-urban parcels.
- PACE is staffing-heavy and the work is among the hardest in healthcare. The building is one of the few burnout levers you control, so real back-of-house, clean circulation, and staff parking protect the retention the model depends on.
- Timelines are long because state licensing, CMS program approval, and a higher life-safety bar run alongside a rare site search and a large build.
- Program from the care model first, solve the kitchen and van circulation early, and sequence licensing in parallel with the build.
The Bottom Line
PACE real estate rewards teams that respect how different it is. The building serves a full day, not a stream of appointments; the site has to move a van fleet, not just park cars; and the regulatory runway is long enough that it has to start with the real estate, not after it.
Treat it like a medical office project and the building will fight the program for years. Program it from the participant's day, choose a site that can move vans, and start the licensing clock early, and the real estate becomes what it should be: the platform that lets the care model run.
Frequently asked questions
What are the real estate requirements for a PACE center?
A PACE center needs large open adult day health and dining space sized to a per-participant minimum, an integrated clinic with exam and treatment rooms, a rehab gym for physical and occupational therapy, a commercial kitchen, and a transportation hub with covered van drop-off, accessible boarding, staging, and fleet parking. It also has to meet a higher life-safety standard for a frail, non-ambulatory population.
How big is a PACE center?
It varies with participant capacity, but PACE centers commonly run in the tens of thousands of square feet because they combine day-program space, a clinic, a rehab gym, and a kitchen under one roof, plus a site large enough for van circulation and fleet parking. That footprint is a major reason many PACE projects become big-box conversions or ground-up builds rather than standard suites.
Why can't a PACE program use a standard medical office building?
A medical office building is designed for throughput, with small exam-room-dense suites and quick visits. A PACE participant is on site for the day, so the building must provide open communal space, meals from a commercial kitchen, on-site therapy and care, and van transportation. Those requirements do not fit the layout or the site of a typical MOB.
What makes PACE site selection different?
The van fleet. A PACE site must let vans pull in, board frail and wheelchair-using participants safely under cover, and pull out many times a day, which requires drive aisles, a sallyport, staging, and fleet parking on top of a large building footprint. The site also has to sit close to the eligible senior population, and those requirements pull against each other, which lengthens the search.
How does staffing affect PACE center design?
PACE runs on a large interdisciplinary team on site all day, doing some of the hardest, most emotionally demanding work in healthcare. Staff turnover is a major risk to the program, and the building is one of the few burnout levers an operator controls. That makes real back-of-house essential: functional staff workstations, an interdisciplinary team room, a genuine break space to decompress, clean staff circulation, and staff parking planned alongside the van fleet rather than squeezed in after. Designing for the team protects the retention and continuity of care the model depends on.
Planning a PACE Center?
I help PACE operators program the building from the care model, find sites that can move a van fleet, and sequence the licensing runway alongside the build. If you're evaluating a site or a conversion, now is the time to pressure-test it.
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