CMS Pub. 100-11, ch. 8, § 30.2

PACE care planning is the responsibility of the IDT members that deliver direct care to

participants in the PACE center they attend and/or in alternative settings such as their

homes or inpatient facilities when dictated by their healthcare needs. A key component of

the PACE model is IDT members’ identification of participant needs in all care domains

(medical, psychosocial, physical, cognitive, functional, and end-of-life), and the IDT’s

coordinated response to these needs. Each member of the team acts within his/her

authorized scope of practice, in accordance with participant preferences, working in

unison with other IDT members to meet the identified needs and achieve each

participant’s optimal outcomes. Optimal outcomes will differ for each participant, but the

plan of care is the roadmap to meet the participant- and team-defined outcomes as

measured after implementation of focused interventions over a prescribed period of time.

Each participant is assigned, at enrollment, to an IDT team that operates at the PACE

center the participant attends. The intent of having this broad-based team is to maximize

the expert services dedicated to the holistic care of each participant.

[42 CFR §§ 460.104; 460.106]