PACE: Care Planning Guidance

PACE: Care Planning Guidance 

Care planning for Programs of All-Inclusive Care for the Elderly (PACE) organizations is a unique process in which an interdisciplinary team assesses participant needs, develops a comprehensive plan of care, and holistically manages the care of frail elderly individuals. Interdisciplinary care planning is a cornerstone of the PACE model of care. Note: Unless otherwise stated, the information in this course was sourced from the Centers for Medicare & Medicaid Services, or CMS, manual for PACE programs last updated 2011. This course was updated to reflect changes due to the Medicare and Medicaid Programs; Programs for All-Inclusive Care for the Elderly (PACE) Final Rule, 2019.


Hours: 0.75


Certificates provided by accrediting body (0 Match)

Course Details

Course Code: REL-SRC-0-PCPG
Hours: 0.75
Type: Online Course
Content Expiration Date: 11/30/2023
Learning Objectives:
Discuss the importance of the interdisciplinary team, or IDT.
Describe the development and maintenance of a care plan.
Name two important areas for which a PACE must develop policies and procedures.

Section 1: Introduction

About This Course

Learning Objectives

Section 2: The Purpose and the Team

Care Planning

The Interdisciplinary Team

The Role of the Physician

Employed or Contracted IDT Members



Section 3: Type of Assessments and Development

Comprehensive Assessment

Home Assessment

Care Plan Development

Meet Joe

Initial Care Plan

Progress Notes vs. Care Plan



Section 4: Conclusion


Course Contributor




Exam and BrainSparks

Expert Reviewer: Ursula Robinson LCSW, MHA
Ursula Robinson LCSW, MHA is the Executive Director of PACE of Guilford and Rockingham Counties, PACE of the Triad, located in Greensboro, NC. Ursula served on the planning committee to evaluate the feasibility of bring PACE to Greensboro and was hired as the first Executive Director in 2010. Under her leadership, PACE of the Triad is the fourth largest PACE program in NC and the first PACE program in North Carolina to provide an Alternative Care Setting to serve rural participants. PACE of the Triad has grown from a start-up operation with one employee in 2010 to 82 employees, volunteers and over 250 acute, long-term care, and medical specialist providers. PACE of the Triad’s annual budget was $16M in in 2016. The organization has served approximately 400 participants and families since inception. Prior to PACE, Ursula was employed with Hospice and Palliative Care of Greensboro for 18 years in various progressive leadership roles. She currently serves on the following Board of Directors: Greensboro Urban Ministries, NC LeadingAge and North Carolina PACE Association. Ursula has taught at Duke’s Divinity School, UNC-G’s School of Social Work, and The National Hospice and Palliative Care Organization’s Leadership Program. She has a master’s degree in Health Care Administration from Pfeiffer University and a master’s degree in Social Worker from UNC-Chapel Hill. She earned her bachelor degree in Social Work from UNC-G. She is a licensed Clinical Social Worker and National LeadingAge Fellow. Some of Ursula’s awards include The Greensboro Chapter of NAACP’s Community Service Award and The North Carolina PACE Association’s Leadership Award. Disclosure: Ursula Robinson LCSW, MHA has declared that no conflict of interest, Relevant Financial Relationship or Relevant Non-Financial Relationship exists.
Staff Writer: Jessica Cairns, RN, RAC-CT, CMAC
Jessica has almost 15 years of experience in nursing and 10 years in MDS/PAC working with organizations for the purposes of assessment, reimbursement, training, organizational, and leadership development. In these roles, she has acted as a consultant and auditor. Jessica has written content for diverse healthcare topics, including health and human services, compliance and more. Disclosure: Jessica Cairns, RN, RAC-CT, CMAC has declared that no conflict of interest, Relevant Financial Relationship or Relevant Non-Financial Relationship exists.
Instructor: Ron Orth RN, CHC, CMAC, AHIMA-Approved ICD-10-CM Trainer
Ronald Orth, RN, CMAC, CHC  obtained a nursing degree from Milwaukee Area Technical College in 1985 and a B. A. in Health Care Administration from Concordia University in 1996. Mr. Orth possesses over 30 years of nursing experience with over 20 of those in the Skilled Nursing industry. Mr. Orth has extensive experience in teaching Medicare regulations to healthcare providers both in the US and internationally. Mr. Orth is currently the Post-acute Care Curriculum Designer and is certified in Healthcare Compliance through the Compliance Certification Board (CCB). Ron has also successfully completed the Infection Control Officer training through the AHCA and is an AHIMA approved ICD-10-CM trainer. Disclosure: Ron Orth RN, CHC, CMAC, AHIMA-Approved ICD-10-CM Trainer has declared that no conflict of interest, Relevant Financial Relationship or Relevant Non-Financial Relationship exists.
Target Audience:
The target audience for this course is: Administrators; in the following settings: Post-Acute Care.
Relias will be transparent in disclosing if any commercial support, sponsorship or co-providership is present prior to the learner completing the course.
Course Delivery Method and Format
Asynchronous/Online Distance Learning; please see certificate details for specifics on delivery format.
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All characteristics and organizations referenced in the following training are fictional. Any resemblance to any actual organizations or persons living or dead, is purely coincidental.
To earn continuing education credit for this course you must achieve a passing score of 80% on the post-test and complete the course evaluation.
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