PACE program software that keeps the interdisciplinary team on one participant record
A PACE program is a Program of All Inclusive Care for the Elderly: a capitated Medicare and Medicaid benefit that keeps a nursing home eligible person living in the community. Under 42 CFR 460.150 a participant must be 55 years of age or older and be found by the state to need nursing facility level of care. 42 CFR 460.102 requires an interdisciplinary team covering 11 named roles at each centre, from the primary care physician to the driver. Neurobird holds the assessments, the care plan and the service decisions on one participant record.
Neurobird PACE Program in short
- Hold the initial comprehensive assessment by discipline, so the team sees who has been in the room and who has not
- Run the 48 hour and 7 calendar day review clocks on recommendations rather than leaving them in an inbox
- Tie every care plan revision to the assessment or event that caused it
- 55 years To enrol, an individual must be 55 years of age or older, live in the service area and be determined by the state to need nursing facility level of care. eCFR, 42 CFR 460.150
- 460.102 The interdisciplinary team must cover 11 named roles at each centre, from the primary care physician and registered nurse through to the personal care attendant and the driver. eCFR, 42 CFR 460.102
- Pricing runs 399 to 1799 US dollars per month across 3 tiers. Early access is free.
What PACE organisations actually deal with
Why it stays broken
A PACE organisation is a clinic, a day centre, a transport operation and an insurer at once. Electronic health records were built for encounters, claims systems were built for billing, and the thing PACE actually runs on is a team decision about one person. The team record is the product, and no vendor ships it, so it becomes a shared drive.
42 CFR 460.102 gives the team no more than 48 hours to review a recommendation from a hospital, emergency department or urgent care provider, and 7 calendar days for recommendations from other staff and contractors.
Within 30 days of the date of enrollment, the interdisciplinary team must consolidate discipline-specific assessments into a single plan of care for each participant through team discussions and consensus of the entire interdisciplinary team.
Neurobird PACE Program Operations Platform
One record per participant: every discipline assessment, the care plan that came out of it, the service determinations with their clocks, and the reassessments that changed the plan.
- 1Hold the initial comprehensive assessment by discipline, so the team sees who has been in the room and who has not
- 2Run the 48 hour and 7 calendar day review clocks on recommendations rather than leaving them in an inbox
- 3Tie every care plan revision to the assessment or event that caused it
- 4Track annual recertification of nursing facility level of care alongside the semiannual reassessments
What changes with Neurobird PACE Program?
The same work, read left to right: how it runs today, and how it runs once the record is in one place.
| Today | With Neurobird PACE Program |
|---|---|
| Eleven disciplines assess the same participant and the findings end up in eleven places | Hold the initial comprehensive assessment by discipline, so the team sees who has been in the room and who has not |
| A recommendation comes back from an emergency department and the clock on reviewing it starts in somebody's inbox | Run the 48 hour and 7 calendar day review clocks on recommendations rather than leaving them in an inbox |
| The semiannual reassessment is due and nobody can see which disciplines have already been in the room | Tie every care plan revision to the assessment or event that caused it |
Who is this for?
The same participant, three different pressures.
You are standing up the programme
The team structure and the review clocks are the whole compliance surface. You need them built into the record from the first participant.
You run several centres
Participants move between centres and teams. The assessments and the plan have to follow the person, not the building.
You are adding participants faster than staff
Reassessment volume grows quietly until it is late. You need what is due next to be a list rather than a memory.
A participant, as your team would work it
Tick a step to move a participant from enquiry to care plan and watch the review clocks appear.
| Requirement | Status | Next due | |
|---|---|---|---|
| Okonkwo, semiannual reassessment | current | in 42d | |
| Ferreira, enrolment assessment due | due soon | in 9d | |
| Vasquez, annual level of care recertification | current | in 120d | |
| Nakashima, hospital discharge recommendation | overdue | 3d late | |
| Nakashima, hospital discharge recommendation | current | in 64d |
Tick a requirement to file evidence against it.
What the rules say about running a PACE program
Eligibility, team composition and the review clocks a PACE organisation is audited against.
To enrol, an individual must be 55 years of age or older, live in the service area and be determined by the state to need nursing facility level of care.
eCFR, 42 CFR 460.150The interdisciplinary team must cover 11 named roles at each centre, from the primary care physician and registered nurse through to the personal care attendant and the driver.
eCFR, 42 CFR 460.102Recommendations from hospitals, emergency departments and urgent care providers must be reviewed no later than 48 hours from the time they are made.
eCFR, 42 CFR 460.102(d)Recommendations from other employees and contractors must be reviewed no later than 7 calendar days from the date the recommendation was made.
eCFR, 42 CFR 460.102(d)On at least a semiannual basis the named team members must reassess the participant in person, and revise the plan of care when the reassessment says so.
eCFR, 42 CFR 460.104How does Neurobird PACE Program work?
Assess by discipline
Each required team member records an in person assessment against the participant, and the gaps are visible before the team meets rather than after.
Decide as a team
Service determinations, approvals and denials are recorded with the clock they came under, so a review that ran late is a fact rather than an argument.
Reassess on time
Semiannual and unscheduled reassessments, plus the state annual recertification, sit on the same record as the plan they change.
Pace program software questions, answered
Key terms
- What is a PACE program?
- A Program of All Inclusive Care for the Elderly. It is a capitated Medicare and Medicaid benefit run under 42 CFR part 460 in which one organisation provides and pays for all needed care. To enrol, a person must be 55 or older, live in the service area and be determined by the state to need nursing facility level of care.
Who sits on the interdisciplinary team?
42 CFR 460.102 names 11 roles, including a primary care physician, a registered nurse, a social worker, a dietitian, a recreational therapist or activity coordinator, a home care coordinator, a personal care attendant and a driver. One person may fill two roles where they are qualified and licensed for both.
How quickly must a recommendation be reviewed?
No later than 48 hours for recommendations from hospitals, emergency departments and urgent care providers, and no later than 7 calendar days for recommendations from other employees and contractors.
Does this replace our electronic health record?
No. It sits beside it. Clinical documentation stays where it is. This holds the team record: who assessed, when, what the team decided, under which clock, and what the plan says now.
How does it handle reassessment?
Semiannual reassessments, unscheduled reassessments after a change in condition and the annual state recertification of level of care all appear on the same participant record, with what is due next visible rather than remembered.
Why we are building this
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Where the requirement comes from
Primary sources, straight from the regulators.
- eCFR, 42 CFR part 460, PACE The whole programme regulation: application, services, participant rights, enrolment and quality.
- eCFR, 42 CFR 460.102, interdisciplinary team The 11 roles, the review clocks on recommendations and the documentation the team owes.
- eCFR, 42 CFR 460.104, assessment and reassessment Who must assess in person, what triggers an unscheduled reassessment and when the plan is revised.
- eCFR, 42 CFR 460.150, eligibility to enrol The age, service area and nursing facility level of care conditions for enrolment.
- CMS, PACE quality monitoring and reporting guidance What gets reported, on what cycle, and the root cause analysis expected after a reportable incident.
How much does Neurobird PACE Program cost?
Priced per centre, because the team, the state agreement and the audit are centre level things. Participants, assessments and care plan versions are unlimited on every tier.
- One PACE centre
- Unlimited participants
- Team assessment record
- Review clock alerts
- Up to 4 centres
- Care plan versioning
- Service determination log
- Reporting exports
- Unlimited centres
- State specific recertification rules
- Quality reporting pack
- Priority support
Get free early access
Early access means we build the assessment and review structure around the state you operate in, and you keep the account free while we do it.
Straight answer on where this is: The software is in development. Nothing is purchasable today. Early access means you shape it and pay nothing while we build.
Prefer email? Write to office@neurobird.com and a person will reply. No autoresponder.