P.A.C.E. — The Patient-Accountability Care Ecosystem

A patient-centered, accountable care ecosystem — powered by AI, designed to help health systems deliver continuous, connected care for midlife women.

Patent Pending · USPTO #64/072,258

Some of the picture already exists, scattered across providers. Some of it is simply missing. P.A.C.E. closes both gaps.

The Problem

Three root causes, one system to solve them

Fragmented, Siloed Care

No single entity is accountable for the whole patient — screenings, specialists, and follow-ups happen in isolation.

Misaligned Financial Incentives

Fee-for-service rewards volume and late-stage intervention over prevention and coordination.

Structural Burden on Patients

Women are left to self-coordinate across disconnected providers, with no one holding the full picture.

What Accountability Actually Means

One Patient. One Ecosystem. Shared Accountability.

Today

The PCP is accountable for their visit.
The OB/GYN is accountable for theirs.
The specialist is accountable for theirs.
The patient is left accountable for connecting it all.

With P.A.C.E.

The ecosystem shares accountability for making sure the patient never falls through the gaps between providers, specialties, screenings, referrals, and follow-up.

How It Works

One model, five pillars

PACE doesn't deliver care itself — it assists and enables your own providers to see the whole patient, across every clinical area that matters in midlife.

Cardiovascular — Heart disease risk rises sharply after menopause, as declining estrogen affects cholesterol and vascular health. It's the leading cause of death for women over 50.

Bone Health — Women can lose up to 20% of bone density in the five to seven years following menopause, driving a steep rise in osteoporosis and fracture risk.

Breast Health — Breast cancer risk increases with age, and hormonal shifts during perimenopause and menopause change breast tissue in ways that affect long-term risk.

Colorectal — Colorectal cancer risk climbs steadily through midlife, with hormonal changes and family history both playing a meaningful role.

Hormonal & Metabolic — The menopause transition reshapes metabolism — raising the risk of insulin resistance, weight redistribution, and thyroid changes.

The five pillars provide the clinical framework — P.A.C.E. also draws on medical and family history, SDOH, behavioral health, and chronic disease management to build the complete picture.

The P.A.C.E. Cell

A coordinated care team covering 5,000 patients — your PCPs plus a specialist bench across all five pillars, working from one shared, accountable view of each patient.

AI Coordinator

Helps the care team see what fragmented care misses — bringing together information that already exists across the health system, but that no single encounter has time to fully connect.

The Model at a Glance

The patient is the center

P.A.C.E. is the ecosystem and accountability layer connecting everyone around her — not a linear hand-off from one provider to the next.

The Patient Journey

A three-tier path of care

TIER 1

Enrollment & Assessment

Outreach and consent, then an Annual Wellness Visit — PCP-led, all five pillars screened. A PACE Risk Score is calculated and the patient is automatically routed to the right next step.

TIER 2

Specialist Screening

Findings route directly to the matching pillar specialist within the Cell — no separate referral process to fall through the cracks of.

TIER 3

Escalation

Emergency, inpatient, or outpatient procedures get coordinated follow-up — the thread never gets dropped.

Outside the Tier Model — Transversal Urgent Tracks

Time-critical pathways that can trigger from any tier — like an oncology referral, run on a fixed 10-business-day clock — so urgency never waits on the normal sequence.

Harvard Medical School GHLP Capstone Patent Pending NC Benefit Corporation

See what this looks like at your health system

Every conversation starts with where you're losing women today — and what closing that gap is worth.

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