BRISTOL, R.I. — At age 82, Roberta Rabinovitz realized she had no place to go. A widow, she had lost both her daughters to cancer, after living with one and then the other, nursing them until their deaths. Then she moved in with her brother in Florida, until he also died.

And so last fall, while recovering from lung cancer, Rabinovitz ended up at her grandson’s home in Burrillville, Rhode Island, where she slept on the couch and struggled to navigate the steep staircase to the shower. That wasn’t sustainable, and with apartment rents out of reach, Rabinovitz joined the growing population of older Americans unsure of where to lay their heads at night.

But Rabinovitz was fortunate. She found a place to live, through what might seem an unlikely source — a health care nonprofit, the . Around the country, arranging for housing is a relatively new and growing challenge for such PACE groups, which are funded through Medicaid and Medicare. PACE stands for a Program of All-Inclusive Care for the Elderly, and the organizations aim to keep frail, older people in their homes. But a patient can’t stay at home if they don’t have one.

As housing costs rise, organizations responsible for people’s medical care are realizing that to ensure their clients have a place to live, they must venture outside their lanes. Even hospitals — in Denver, , and — have started investing in housing, recognizing that health isn’t possible without it.

And among older adults, the need is especially growing. In the U.S., who were homeless in 2024 were 55 or older, with the total older homeless population up 6% from the previous year. a University of Pennsylvania professor who specializes in homelessness and housing policy, older than 60 living in shelters roughly tripled from 2000 to 2020.

“It’s a national scandal, really, that the richest country in the world would have destitute elderly and disabled people,” Culhane said.

Over decades of research, Culhane has documented the plight of people born between 1955 and 1965 who and never got an economic foothold. Many in this group endured intermittent homelessness throughout their lives, and now their troubles are compounded by aging.

But other homeless older adults are new to the experience. Many teeter on the edge of poverty, said , CEO of USAging, a national association representing what are known as . A single incident can tip them into homelessness — the death of a spouse, job loss, a rent increase, an injury or illness. If cognitive decline starts, an older person may forget to pay their mortgage. Even those with paid-off houses often can’t afford rising property taxes and upkeep.

“No one imagines anybody living on the street at 75 or 80,” Markwood said. “But they are.”

President Donald Trump’s recent budget law, , the public insurance program for those with low incomes or disabilities, will make matters worse for older people with limited incomes, said Yolanda Stevens, program and policy analyst with the . If people lose their health coverage or their local hospital closes, it will be harder for them to maintain their health and pay the rent.

“It’s a perfect storm,” Stevens said. “It’s an unfortunate, devastating storm for our older Americans.”

Adding to the challenges, the Labor Department a job training program intended to keep low-income older people in the workforce.

Those circumstances have sent PACE health plans throughout the country into uncharted waters, prompting them to set up shop , partner with housing providers, or even to build their own.

A 1997 federal law recognized PACE organizations as a provider type for Medicare and Medicaid. Today, some 185 operate in the U.S., each serving a defined geographic area, with a total of more than .

They enroll people 55 and older who are sick enough for nursing home care, and then provide everything their patients need to stay home despite their frailty. They also run centers that function as medical clinics and adult day centers and provide transportation.

These organizations primarily serve impoverished people with complex medical conditions who are eligible for both Medicaid and Medicare. They pool money from both programs and operate within a set budget for each participant.

PACE officials worry that, as federal funding for Medicaid programs shrinks, states will curtail support. But the PACE concept has always had bipartisan support, said Robert Greenwood, a senior vice president at the , because its services are significantly less expensive than nursing home care.

The financing structure gives PACE the flexibility to do what it takes to keep participants living on their own, even if it means buying an air conditioner or taking a patient’s dog to the vet. Taking on the housing crisis is another step toward the same goal.

In the Detroit area, , which serves 2,200 participants, partners with the owners of senior housing. The landlords agree to keep the rent affordable, and PACE provides services to their tenants who are members. Housing providers “like to be full, they like their seniors cared for, and we do all of that,” said Mary Naber, president and CEO of PACE Southeast Michigan.

For participants who become too infirm to live on their own, the Michigan organization has leased a wing in an independent living center, where it provides round-the-clock supportive care. The organization also is partnering with a nonprofit developer to create a cluster of 21 shipping containers converted into little houses in Eastpointe, just outside Detroit. Still in the planning stages, Naber said, the refurbished containers will probably rent for about $1,000 to $1,100 a month.

In San Diego, the cares for chronically homeless people as they move into housing, offering not just health services but the backup needed to keep tenants in their homes, such as guidance on paying bills on time and keeping their apartments clean. St. Paul’s also helps those already in housing but clinging to precarious living arrangements, said Carol Castillon, vice president of its PACE operations, by connecting them with community resources, helping fill out forms for housing assistance, and providing meals and household items to lower expenses.

At PACE Rhode Island, which serves nearly 500 people, about 10 to 15 participants each month become homeless or at risk of homelessness, a rare situation five or six years ago, CEO Joan Kwiatkowski said.

The organization contracts with assisted living facilities, but its participants are sometimes rejected because of prior criminal records, substance use, or health care needs that the facilities feel they can’t handle. And public housing providers often have no openings.

So PACE Rhode Island is planning to buy its own housing, Kwiatkowski said. PACE also has reserved four apartments at an assisted living facility in Bristol for its participants, paying rent when they’re unoccupied. Rabinovitz moved into one recently.

Rabinovitz had worked as a senior credit analyst for a health care company, but now her only income is her Social Security check. She keeps $120 from that check for personal supplies, and the rest goes to rent, which includes meals.

Once a week or so, Rabinovitz rides a PACE van to the organization’s center, where she gets medical care, including dental work, physical therapy, and medication — always, she said, from “incredibly loving people.” When she’s not feeling well enough to make the trek, PACE sends someone to her. Recently, a technician with a portable X-ray machine scanned her sore hip as she lay in her own bed in her new studio apartment.

“It’s tiny, but I love it,” she said of the apartment, which she’s decorated in purple, her favorite color.

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He didn’t need to be in the hospital any longer. But he was still in pain, unsteady on his feet, unready for independence.

Patients nationwide often stall at this intersection, stuck in the hospital for days or weeks because nursing homes and physical rehabilitation facilities are full. Yet when Durocher was ready for discharge in late January, a clinician came by with a surprising path forward: Want to go home?

Specifically, he was invited to join a research study at UMass Chan Medical School in Worcester, Massachusetts, testing the concept of “SNF at home” or “subacute at home,” in which services typically provided at a skilled nursing facility are instead offered in the home, with visits from caregivers and remote monitoring technology.

Durocher hesitated, worried he might not get the care he needed, but he and his wife, Jeanne, ultimately decided to try it. What could be better than recovering at his home in Auburn with his dog, Buddy?

Such rehab at home is underway in various parts of the country — including New York, Pennsylvania, and Wisconsin — as a solution to a shortage of nursing home and rehab beds for patients too sick to go home but not sick enough to need hospitalization.

Staffing shortages at post-acute facilities around the country led to a 24% increase over three years in hospital length of stay among patients who need skilled nursing care, according to a . With no place to go, these patients occupy expensive hospital beds they don’t need, while others wait in emergency rooms for those spots. In Massachusetts, for example, at least 1,995 patients were awaiting hospital discharge in December, according to a by the Massachusetts Health & Hospital Association.

Offering intensive services and remote monitoring technology in the home can work as an alternative — especially in rural areas, where nursing homes are than in cities and patients’ relatives often must travel far to visit. For patients of the Marshfield Clinic Health System who live in rural parts of Wisconsin, the clinic’s six-year-old SNF-at-home program is often the only option, said , medical director of the hospital-at-home program.

“This is going to be the future of medicine,” Gudibanda said.

But the concept is new, an outgrowth of hospital-at-home services expanded by a covid-19 pandemic-inspired Medicare waiver. SNF-at-home care remains uncommon, lost in a fiscal and regulatory netherworld. No federal standards spell out how to run these programs, which patients should qualify, or what services to offer. No reimbursement mechanism exists, so fee-for-service Medicare and most insurance companies don’t cover such care at home.

The programs have emerged only at a few hospital systems with their own insurance companies (like the Marshfield Clinic) or those that arrange for “bundled payments,” in which providers receive a set fee to manage an episode of care, as can occur with Medicare Advantage plans.

In Durocher’s case, the care was available — at no cost to him or other patients — only through the clinical trial, funded by a grant from the state Medicaid program. State health officials supported two simultaneous studies at UMass and Mass General Brigham hoping to reduce costs, improve quality of care, and, crucially, make it easier to transition patients out of the hospital.

The American Health Care Association, the trade group representing more than 15,000 long-term and post-acute care providers, calls “SNF at home” a misnomer because, by law, such services must be provided in an institution and meet detailed requirements. And the association points out that skilled nursing facilities provide services and socialization that can never be replicated at home, such as daily activity programs, religious services, and access to social workers.

But patients at home tend to get up and move around more than those in a facility, speeding their recovery, said , medical director of the UMass Chan clinical trial. Also, therapy is tailored to their home environment, teaching patients to navigate the exact stairs and bathrooms they’ll eventually use on their own.

A quarter of people who go into nursing homes suffer an “adverse event,” such as infection or bed sore, said , clinical director for research for Mass General Brigham’s Healthcare at Home program and leader of its study. “We cause a lot of harm in facility-based care,” he said.

By contrast, in 2024, not one patient in the Rehabilitation Care at Home program of Nashville-based Contessa Health developed a bed sore and only 0.3% came down with an infection while at home, according to internal company data. Contessa delivers care in the home through partnerships with five health systems, including Mount Sinai Health System in New York City, the Allegheny Health Network in Pennsylvania, and Wisconsin’s Marshfield Clinic.

Contessa’s program, which has been providing in-home post-hospital rehabilitation since 2019, depends on help from unpaid family caregivers. “Almost universally, our patients have somebody living with them,” said , Contessa’s acting president and chief medical officer.

The two Massachusetts-based studies, however, do enroll patients who live alone. In the UMass trial, an overnight home health aide can stay for a day or two if needed. And while alone, patients “have a single-button access to a live person from our command center,” said , an assistant professor of medicine at UMass Chan and the leader of its study.

But SNF at home is not without hazards, and choosing the right patients to enroll is critical. The UMass research team learned an important lesson when a patient with mild dementia became alarmed by unfamiliar caregivers coming to her home. She was readmitted to the hospital, according to Mitchell.

The Mass General Brigham study relies heavily on technology intended to reduce the need for highly skilled staff. A nurse and physician each conducts an in-home visit, but the patient is otherwise monitored remotely. Medical assistants visit the home to gather data with a portable ultrasound, portable X-ray, and a device that can analyze blood tests on-site. A machine the size of a toaster oven dispenses medication, with a robotic arm that drops the pills into a dispensing unit.

The UMass trial, the one Durocher enrolled in, instead chose a “light touch” with technology, using only a few devices, Soni said.

The day Durocher went home, he said, a nurse met him there and showed him how to use a wireless blood pressure cuff, wireless pulse oximeter, and digital tablet that would transmit his vital signs twice a day. Over the next few days, he said, nurses came by to take blood samples and check on him. Physical and occupational therapists provided several hours of treatment every day, and a home health aide came a few hours a day. To his delight, the program even sent three meals a day.

Durocher learned to use the walker and how to get up the stairs to his bedroom with one crutch and support from his wife. After just one week, he transitioned to less-frequent, in-home physical therapy, covered by his insurance.

“The recovery is amazing because you’re in your own setting,” Durocher said. “To be relegated to a chair and a walker, and at first somebody helping you get up, or into bed, showering you — it’s very humbling. But it’s comfortable. It’s home, right?”

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Now in her final year at the Mineola, New York, school, Lo Cascio remains committed to primary care pediatrics. But many young doctors choose otherwise as they leave medical school for their residencies. In 2024, went unfilled and family medicine programs faced as students chased higher-paying specialties.

Lo Cascio, 24, said her three-year accelerated program nurtured her goal of becoming a pediatrician. Could other medical schools do more to promote primary care? The question could not be more urgent. The Association of American Medical Colleges of 20,200 to 40,400 primary care doctors by 2036. This means many Americans will lose out on the benefits of primary care, which research shows improves health, leading to fewer hospital visits and less chronic illness.

Many medical students start out expressing interest in primary care. Then they end up at schools based in academic medical centers, where students become enthralled by complex cases in hospitals, while witnessing little primary care.

The driving force is often money, said , a physician and a senior vice president at the American Board of Family Medicine. “Subspecialties tend to generate a lot of wealth, not only for the individual specialists, but for the whole system in the hospital,” he said.

A department’s cache of federal and pharmaceutical-company grants often determines its size and prestige, he said. And at least , including Harvard, Yale, and Johns Hopkins, don’t even have full-fledged family medicine departments. Students at these schools can study internal medicine, but many of those graduates end up choosing subspecialties like gastroenterology or cardiology.

One potential solution: eliminate tuition, in the hope that debt-free students will base their career choice on passion rather than paycheck. In 2024, two elite medical schools — the and — announced that charitable donations are enabling them to waive tuition, joining a handful of other tuition-free schools.

But the contrast between the school Lo Cascio attends and the institution that founded it starkly illustrates the limitations of this approach. Neither charges tuition.

In 2024, graduating from her Long Island school chose residencies in primary care. Lo Cascio said the tuition waiver wasn’t a deciding factor in choosing pediatrics, among the lowest-paid specialties, with an average annual income of $260,000, according to .

At the sister school, the Manhattan-based NYU Grossman School of Medicine, chose specialties like orthopedics (averaging $558,000 a year) or dermatology ($479,000).

Primary care typically gets little respect. Professors and peers alike admonish students: If you’re so smart, why would you choose primary care? Anand Chukka, 27, said he has heard that refrain regularly throughout his years as a student at Harvard Medical School. Even his parents, both PhD scientists, wondered if he was wasting his education by pursuing primary care.

Seemingly minor issues can influence students’ decisions, Chukka said. He recalls envying the students on hospital rotations who routinely were served lunch, while those in primary care settings had to fetch their own.

Despite such headwinds, Chukka, now in his final year, remains enthusiastic about primary care. He has long wanted to care for poor and other underserved people, and a one-year clerkship at a community practice serving low-income patients reinforced that plan.

When students look to the future, especially if they haven’t had such exposure, primary care can seem grim, burdened with time-consuming administrative tasks, such as seeking prior authorizations from insurers and grappling with electronic medical records.

While specialists may also face bureaucracy, primary care practices have it much worse: They have more patients and less money to hire help amid burgeoning paperwork requirements, said , chair of family medicine at Brown University’s Warren Alpert Medical School.

“It’s not the medical schools that are the problem; it’s the job,” Richardson said. “The job is too toxic.”

, a professor of family and community medicine at the University of California-San Francisco, spent decades trying to boost the share of students choosing primary care, only to conclude: “There’s really very little that we can do in medical school to change people’s career trajectories.”

Instead, he said, the U.S. health care system must address the low pay and lack of support.

And yet, some schools find a way to produce significant proportions of primary care doctors — through recruitment and programs that provide positive experiences and mentors.

U.S. News & World Report 168 medical schools of graduates who were practicing primary care six to eight years after graduation.

The top 10 schools are all osteopathic medical schools, with 41% to 47% of their students still practicing primary care. Unlike allopathic medical schools, which award MD degrees, osteopathic schools, which award DO degrees, have a history of focusing on primary care and are graduating a growing share of the nation’s primary care physicians.

At the bottom of the U.S. News list is Yale, with 10.7% of its graduates finding lasting careers in primary care. Other elite schools have similar rates: Johns Hopkins, 13.1%; Harvard, 13.7%.

In contrast, public universities that have made it a mission to promote primary care have much higher numbers.

The University of Washington — No. 18 in the ranking, with 36.9% of graduates working in primary care — has a placing students in remote parts of Washington, Wyoming, Alaska, Montana, and Idaho. UW recruits students from those areas, and many go back to practice there, with more than 20% of graduates settling in rural communities, according to , assistant dean for clinical curriculum.

Likewise, the University of California-Davis (No. 22, with 36.3% of graduates in primary care) increased the percentage of students choosing family medicine from 12% in 2009 to 18% in 2023, even as it ranks high in specialty training. Programs such as an accelerated three-year primary care “pathway,” which enrolls primarily first-generation college students, help sustain interest in non-specialty medical fields.

The effort starts with recruitment, looking beyond test scores to the life experiences that forge the compassionate, humanistic doctors most needed in primary care, said associate dean for admissions and outreach. Most of the students have families who struggle to get primary care, he said. “So they care a lot about it, and it’s not just an intellectual, abstract sense.”

Establishing schools dedicated to primary care, like the one on Long Island, is not a solution in the eyes of some advocates, who consider primary care the backbone of medicine and not a separate discipline. , executive director of the Social Mission Alliance at the Fitzhugh Mullan Institute of Health Workforce Equity, worries that establishing such schools might let others “off the hook.”

Still, attending a medical school created to produce primary care doctors worked out well for Lo Cascio. Although she underwent the usual specialty rotations, her passion for pediatrics never flagged — owing to her 23 classmates, two mentors, and her first-year clerkship shadowing a community pediatrician. Now, she’s applying for pediatric residencies.

Lo Cascio also has deep personal reasons: Throughout her experience with a congenital heart condition, her pediatrician was a “guiding light.”

“No matter what else has happened in school, in life, in the world, and medically, your pediatrician is the person that you can come back to,” she said. “What a beautiful opportunity it would be to be that for someone else.”

Ñî¹óåú´«Ã½Ò•îl Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

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This story can be republished for free (details).