PACE Interdisciplinary Team: IDT-Based Care, Assessment, and Care Planning

This course provides an overview of how the PACE interdisciplinary team (IDT) works together to assess participants, build and update individualized plans of care, and coordinate services across settings within the PACE framework (Program of All-Inclusive Care for the Elderly). Learners will explore required IDT roles, assessment and reassessment processes, and how direct and contracted services are organized under a single plan of care. Through real-world scenarios and problem-solving activities, the course highlights how information flows between the IDT, contracted providers, and support services, and it emphasizes when staff must document and escalate concerns to keep participants safe and at home. The content is suitable for any PACE care employee, with examples that reflect both clinical and nonclinical roles.

Course Objectives:
1. Identify required interdisciplinary team (IDT) roles, and describe their core responsibilities
2. Explain the required assessment and reassessment process and the disciplines involved at each step
3. Describe the elements of an individualized plan of care (POC) and criteria for changing the POC
4. Differentiate between services provided directly by the organization vs. those that can be provided through contracted providers, and outline staff responsibilities when coordinating contracted care
5. Illustrate how information flows between the IDT, contracted providers, and support services, and demonstrate when and how to escalate concerns

This training aligns with federal PACE requirements under 42 C.F.R. Part 460 (including requirements for the interdisciplinary team, assessment, and care planning).

• 42 C.F.R. Part 460

Estimated Runtime: 20 minutes

Reviewed and approved by
Kim Tate, RN, BSN

NOTE: This course is not a substitute for legal advice for any individual provider or situation. Always consult your company’s legal or compliance personnel with any questions or concerns related to this subject matter.