Interdisciplinary team

The interdisciplinary team is the unit of decision in PACE. Under 42 CFR 460.102 each PACE organization must establish one, composed at a minimum of a primary care provider, a registered nurse, a master’s-level social worker, a physical therapist, an occupational therapist, a recreational therapist or activity coordinator, a dietitian, a PACE center manager, a home care coordinator, a personal care attendant and a driver. The team is responsible for the initial assessment, the periodic reassessments, the plan of care, and the coordination of 24-hour care delivery. Services are provided on the team’s decision, and the organization pays for what the team decides.

For the initial comprehensive assessment the regulation names the eight members who must each evaluate the participant in person and write a discipline-specific assessment: the primary care provider, the registered nurse, the social worker, the physical therapist, the occupational therapist, the recreational therapist or activity coordinator, the dietitian and the home care coordinator. Other disciplines, such as speech-language pathology, dentistry or audiology, join on the team’s recommendation. Within 30 days of enrollment the team consolidates those eight assessments into one plan of care “through team discussions and consensus of the entire interdisciplinary team”.

Eight clinicians, eight assessments, one person, inside a month. Each one of them wants the same history: the hospital admissions, the specialists’ findings, the medication list as it actually was before the organization took over, the imaging that explains the gait. When the records arrive one fax at a time the eight assessments are done from eight partial views, and the consensus meeting spends its time reconciling what each member was told. When the outside record arrives organized, before the first assessment, the team starts from the same page.