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Glossary

Initial comprehensive assessment

The in-person assessment the PACE interdisciplinary team must complete on every new participant under 42 CFR 460.104: eight disciplines each evaluate the participant and write a discipline-specific assessment across eleven domains, and the team consolidates them into one plan of care within 30 days of enrollment.

Also PACE initial assessment, IDT assessment, comprehensive assessment (PACE)

The initial comprehensive assessment is the first thing a PACE organization does for a participant and the thing everything after it depends on. 42 CFR 460.104(a) requires the interdisciplinary team to “conduct an initial in-person comprehensive assessment on each participant”, completed “in a timely manner” so that the plan of care can be developed within 30 days of enrollment. The assessment itself carries no day count; the plan it feeds does.

Eight members of the team must each evaluate the participant in person: the primary care provider, the registered nurse, the master’s-level social worker, the physical therapist, the occupational therapist, the recreational therapist or activity coordinator, the dietitian and the home care coordinator. Each writes a discipline-specific assessment. Together they must cover, at a minimum, eleven domains:

  • physical and cognitive function and ability;
  • medication use;
  • participant and caregiver preferences for care;
  • socialization and availability of family support;
  • current health status and treatment needs;
  • nutritional status;
  • home environment, including access and egress;
  • participant behavior;
  • psychosocial status;
  • medical and dental status;
  • participant language.

Under 460.104(b) and 460.106(b)(1) the team then consolidates the eight assessments into a single person-centered plan of care within 30 calendar days of the date of enrollment, by consensus of the whole team. The plan is reevaluated at least every 180 days and within 14 days of a change in the participant’s condition.

“Medication use” and “current health status and treatment needs” are the two domains that cannot be assessed from the participant alone. They are in the hospital’s discharge summaries, the specialists’ notes and the prior primary care record, and a participant with a long history has them in several organizations’ systems. The organization that has those records in hand before the eight visits begin assesses a person; the one that does not assesses a recollection. PACE intake records is written for the first kind.

Where it is defined

Vivlio for paceThe intake checklist, from twelve months of progress notes to the medication list, assembled before the team meets.

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  1. Send your detailsTwo minutes. Your organization, name, email and phone, and the time records cost you; the rest is optional and helps us reply with something specific.
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Who this is for, and who it is not

  • Coverage comes firstVivlio retrieves from providers, hospitals and health systems it can reach through national exchange networks and direct connections. Name the facilities your patients come from on the form and we check coverage before anyone spends thirty minutes on a demo.
  • You can say what the chasing costsThe form asks how many hours a week your team loses to chasing records. If nobody can put a number near it, the case for Vivlio is not there yet, and we would rather say so than sell you a demo.
  • Patients and files at volumeThis is built for intake that runs every day. For one record, once, your patient can request it from the provider directly, and that will be faster than going through us.
  • Treatment, with the paperwork doneProduction access needs an NPI, a declared purpose of use and a signed BAA. Nobody swipes a card onto live PHI.

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