# 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.

- URL: https://neurobird.com/paceprogram/
- Product: Neurobird PACE Program Operations Platform
- Niche: PACE program
- Buyer: PACE organisations
- Status: in development, open for early access
- Updated: 2026-08-22

## What Neurobird PACE Program does

- 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
- Track annual recertification of nursing facility level of care alongside the semiannual reassessments

## How it works

1. **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.
2. **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.
3. **Reassess on time** Semiannual and unscheduled reassessments, plus the state annual recertification, sit on the same record as the plan they change.

## From the source material

> 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.

Source: eCFR, 42 CFR 460.104, assessment and reassessment, https://www.law.cornell.edu/cfr/text/42/460.104

## Industry context

- **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. (source: eCFR, 42 CFR 460.150, https://www.law.cornell.edu/cfr/text/42/460.150)
- **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. (source: eCFR, 42 CFR 460.102, https://www.law.cornell.edu/cfr/text/42/460.102)
- **48 hours** Recommendations from hospitals, emergency departments and urgent care providers must be reviewed no later than 48 hours from the time they are made. (source: eCFR, 42 CFR 460.102(d), https://www.law.cornell.edu/cfr/text/42/460.102)
- **7 calendar days** Recommendations from other employees and contractors must be reviewed no later than 7 calendar days from the date the recommendation was made. (source: eCFR, 42 CFR 460.102(d), https://www.law.cornell.edu/cfr/text/42/460.102)
- **460.104** 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. (source: eCFR, 42 CFR 460.104, https://www.law.cornell.edu/cfr/text/42/460.104)

## Pricing

- Single centre: $399 per month
- Organisation: $899 per month
- Multi state: $1,799 per month

## Questions

### 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.

## Sources

- [eCFR, 42 CFR part 460, PACE](https://www.law.cornell.edu/cfr/text/42/part-460)
- [eCFR, 42 CFR 460.102, interdisciplinary team](https://www.law.cornell.edu/cfr/text/42/460.102)
- [eCFR, 42 CFR 460.104, assessment and reassessment](https://www.law.cornell.edu/cfr/text/42/460.104)
- [eCFR, 42 CFR 460.150, eligibility to enrol](https://www.law.cornell.edu/cfr/text/42/460.150)
- [CMS, PACE quality monitoring and reporting guidance](https://www.cms.gov/files/document/pace-quality-monitoring-and-reporting-guidancejanuary-2024.pdf)

## Contact

- office@neurobird.com
- https://neurobird.com/