All-Inclusive Care Coordination for PACE
The Program of All-Inclusive Care for the Elderly integrates every service a frail elder needs to remain in the community. AssistedCare coordinates the documentation across all those services — medical, therapeutic, social, and transportation — so your interdisciplinary team operates as one.
Challenges in PACE
Coordinating Dozens of Service Types
PACE programs provide primary care, specialty care, therapy, day health services, home care, transportation, meals, and more — often for the same participant on the same day. Without integrated documentation, coordination breaks down.
Large Interdisciplinary Teams Need Shared Records
Physicians, nurses, therapists, social workers, dietitians, activity coordinators, and transportation staff all interact with each participant. When each discipline documents separately, the full picture is never visible.
Capitated Reimbursement Requires Cost Control
PACE programs receive a fixed monthly payment per participant from Medicare and Medicaid. Managing costs against that capitation while delivering comprehensive care requires visibility into service utilization and outcomes.
CMS PACE Audit Requirements Are Extensive
CMS conducts detailed audits of PACE organizations covering enrollment, service delivery, grievances, quality improvement, and financial performance. Incomplete documentation across any area creates audit risk.
How AssistedCare Solves It
Integrated Participant Records
Every service, encounter, assessment, and communication for each participant is documented in one record. The interdisciplinary team sees the complete picture regardless of which service they provide.
See Clinical Charting→IDT Meeting and Care Planning Tools
Interdisciplinary team meetings are supported with pre-compiled participant summaries, goal tracking, and care plan management. Every discipline's input is captured and the resulting plan is shared with the full team.
Service Utilization Analytics
Track which services each participant uses, how frequently, and at what cost. Identify high-utilization participants who may need care plan adjustments and monitor overall program costs against capitation revenue.
Capitated Billing and Encounter Tracking
Manage monthly capitation payments from Medicare and Medicaid while tracking all encounters for CMS reporting requirements. The system ensures that every service delivered is documented and countable.
See Billing Tools→CMS Audit Readiness
Enrollment documentation, service delivery records, grievance tracking, quality improvement data, and financial reports are all maintained in audit-ready format. When CMS arrives, your records are organized and complete.
CMS Readiness→Service Coverage
Less IDT Prep Time
Offline Capability
Participant View
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Frequently Asked Questions
Yes. The system supports documentation for all PACE-covered services: primary and specialty medical care, nursing, physical and occupational therapy, speech therapy, social work, personal care, nutritional counseling, recreational activities, transportation, and day health services.
The enrollment workflow manages the complete process from initial screening and eligibility determination through enrollment agreements and ongoing eligibility monitoring. Disenrollment is documented with reason codes and required notifications.
CMS PACE quality measures are tracked using data from daily operations. The system generates HPMS submissions and monitors performance against quality benchmarks for each reporting period.
With appropriate authorization, family members and caregivers can access participant information, care plan summaries, and appointment schedules through the secure family portal. Communication between the IDT and families is documented.
All data is encrypted at rest and in transit using industry-standard encryption. Access is controlled through role-based permissions that follow the principle of minimum necessary access. We maintain detailed audit logs and conduct regular security assessments.
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