Every PACE program has the same enrollment sequence, and the people who advise programs on growing census agree on where to watch it. Traktion Partners, whose practice is PACE enrollment, puts the sequence as “referral, intake, assessment, enrollment” and says most programs “only notice a problem when monthly enrollment numbers come in low, at which point the cause is already weeks old”. Their advice is to measure time in each stage, and the stage they return to is assessment: “Assessment capacity becomes the constraint”, “Referral volume can scale quickly, but assessment capacity usually doesn’t”, candidates “waiting weeks for an assessment slot”, and “every delay makes it more likely they will choose another option”.
That diagnosis is staffing and scheduling. Across the five Traktion pages on the subject, the words “records”, “medical records” and “documentation” do not appear. Health Dimensions Group’s PACE writing is about census and market penetration (90,580 enrolled at the end of 2025, up 12 percent on the year) and does not touch intake at all. The National PACE Association publishes no referral-to-enrollment figure and no intake conversion benchmark, and neither does CMS. This article is about the cause the consultants’ pages leave out, with the regulators’ own words for it.
What has to happen before enrollment
The federal rule puts two assessments before enrollment, and neither is the one most people picture. Under 42 CFR 460.152, intake is “an intensive process during which PACE staff members make one or more visits to a potential participant’s place of residence and the potential participant makes one or more visits to the PACE center”. The applicant “must sign a release to allow the PACE organization to obtain his or her medical and financial information and eligibility status for Medicare and Medicaid”. Then the state administering agency “must assess the potential participant” for nursing facility level of care, and PACE staff “must assess the potential participant to ensure that he or she can be cared for appropriately in a community setting”.
The eight-discipline, in-person comprehensive assessment under 460.104 comes after. CMS’s PACE Manual is explicit: it “is performed by the Interdisciplinary Team (IDT) on each participant independent of any pre-enrollment screening by the IDT” and “must be completed promptly following enrollment”. So “time in assessment”, as the consultants use the phrase, is the program’s own pre-enrollment screening plus the state’s level-of-care review, both of which run on a document the program has to get from someone else.
Programs say as much to applicants. Sentara PACE’s enrollment page: “The Interdisciplinary Team (IDT) will review your medical records”, and “We will also ask you to give us permission to obtain your medical records from doctors you have seen”. Colorado PACE: the release forms “allow Colorado PACE to obtain your past medical records”. InnovAge: “our senior care experts will help gather your medical records from your current care providers”, after which “InnovAge will submit your PACE application to the state in which you live for their review and final approval”. The sequence inside the assessment stage is gather, then assess, then submit, and the first step has no clock and no owner outside the program.
The state that wrote it down
Most state rules name the assessment tool and the professional who signs it and nothing about what sits underneath. Ohio’s rule gives the level-of-care assessment to the Department of Aging, which “in its discretion, may delegate this responsibility”, and the criteria rest on “an Ohio department of medicaid (ODM)-approved assessment tool” and a cognitive impairment “as diagnosed by a physician”. Michigan’s determination “must be conducted face-to-face by a qualified and licensed health professional and entered into CHAMPS within 14 calendar days from the date it was conducted”. California’s organizations complete a nursing facility level of care form and submit it to an inbox for a DHCS nurse’s review. None of the three lists the records the assessor reads.
Louisiana does, and says what happens without them. The Office of Aging and Adult Services’ PACE Procedures Manual, reissued in March 2025, runs applicants through a telephone screening and then an in-person interRAI Home Care assessment by PACE staff, and “NFLOC eligibility is not confirmed until the iHC assessment is completed and the iHC indicates that NFLOC is met”. When eligibility turns on treatments and conditions, physician involvement or skilled rehabilitation, “the required documentation showing that the PW was met must either be in the iHC notebook or uploaded to the iHC”. Then the sentence the consultants’ pages do not have:
“If all necessary information is not provided, enrollment will be delayed until the OAAS RO has the information needed to confirm that NFLOC is met. The OAAS RO cannot proceed until proper documentation is provided. This must be done by the 15th of the month to ensure enrollment by the 1st of the following month.”
That is a state reviewer, in its own manual, naming the documentation as the thing enrollment waits on, with a date: records in by the 15th or the person waits another month. The safety assessment in the same manual rests on the same kind of document, among its criteria “a physician, familiar with the applicant’s health and social history, has documented a condition that requires 24-hours, 7 days per week of skilled care”.
Pennsylvania’s version is the physician’s form. The state’s 2020 process memo told LIFE providers that if they “have access to the completed Physician Certification Form (MA 570)”, they “should do their best to ensure it be made available during the Functional Eligibility Determination (FED) assessment”, and a discrepancy between the physician’s form and the assessment triggers a medical director review with “a three business day turn-around time”, for which the provider submits the form “and any relevant supporting documentation”. The memo is marked obsolete since 2021, so that is the 2020 process; the form it names is still the one the state requires, signed by an MD or DO.
And Massachusetts, in January 2022, extended the validity of the initial assessment from the usual window to a full year with this explanation: “We recognize that several factors may delay enrollment in PACE.” The factors are not named. A state does not extend a clinical assessment’s shelf life to twelve months because scheduling is tight for a week.
How long the assessment stage is allowed to take
For home and community-based services generally, which is the set of programs the PACE level-of-care determination belongs to, MACPAC’s August 2024 compendium found that “32 states have requirements for how long assessors can take to complete the functional assessment, with a range of 2 to 45 days”, that “17 states have timeframe requirements to approve a LOC assessment for at least one HCBS program in the state, with a range of 5 to 30 days”, and that “32 use record review”, always “combined with another assessment method, such as in person”. Record review is a named assessment method in two thirds of states, and the records have to be there for it to happen.
Then the calendar. Enrollment takes effect on the first of the month, and the National PACE Association’s August 2026 brief for the PACE Access Improvement Act describes the consequence: the rule forces “older adults who urgently need care to wait weeks with no coverage”. Every day the assessment stage stretches past a state’s cutoff is not one day lost but, in Louisiana’s words, “the 1st of the following month”. Florida PACE Centers tells its applicants that “the entire process takes two to three months due to the Department of Children and Families’ (DCF) and the Florida Department of Elder Affairs’ requirements”. That is one program describing its own state, and it is the only kind of figure that exists.
Why the document is slow
No study quantifies records-caused delay in PACE intake, and this article does not pretend one does. What exists is the general evidence about the documents in question, from the settings next door.
Kripalani and colleagues’ 2007 systematic review of hospital-to-primary-care handoffs found a discharge summary available at the first post-discharge visit in 12 to 34 percent of cases and at four weeks in 51 to 77 percent, and the summaries that did arrive missing diagnostic test results 33 to 63 percent of the time, pending results 65 percent of the time, and discharge medications 2 to 40 percent. King and colleagues’ 2013 study of skilled nursing facility nurses found they “rely heavily on written hospital discharge communication” and that its inadequacies “necessitated repeated telephone clarifications, created care delays”. A PACE applicant is, by definition, someone with a nursing facility level of need and a long history across several organizations, which is to say the person for whom these documents are most numerous and most scattered.
And when they do arrive, they have to be read. In April 2026 CMS fined Collabria Care, a California PACE organization, after its audit found that “In eight instances, service recommendations were either never provided to the participants or discussed by the IDT to determine if they were necessary. The identified noncompliance involved recommendations from hospitals’ discharge reports and specialist physicians.” That finding is about participants already enrolled, and the post-enrollment clocks are their own article, but it is a federal regulator naming the hospital discharge report as the document whose contents got lost in a PACE organization.
What to do with the stage
Traktion’s instrument is the right one: measure days in each stage, and treat a rising assessment number as a live signal. The addition is to split the number. Days from referral to the first contact is a staffing figure. Days from the signed release to the last outside record in hand is a retrieval figure, and it is the one that moves a person from this month’s cohort to next month’s when it crosses the state’s cutoff. A program that does not measure it will see the stall as an assessment-capacity problem, hire for it, and find the number does not move.
The retrieval figure has a floor set by the method. Faxed requests to the providers the applicant can name, one at a time, wait on each provider’s release-of-information desk. The alternative is to retrieve the outside record once, through the national record networks, on the release the applicant has already signed: every organization that participates returns what it holds, the discharge documents and the consult notes and the medication history among them, organized by section and date before the home visit rather than after. The state assessor and the program’s own screening then work from the same record, and the documentation Louisiana’s reviewer “cannot proceed” without is in by the 15th. PACE intake records describes that retrieval; the PACE intake timeline carries the federal and state clocks it runs against, and nursing facility level of care, the state administering agency and PACE enrollment carry the regulation text.
