Innovage PACE, a program of all-inclusive care of the elderly, is a fully capitated, fully at risk, value based program funded by state Medicaid funds (straight per member per month based on state legislature) and federal Medicare funding (based on RAF scoring from hierarchical chronic condition ICD-10 scores. To qualify, a participant has to be 55 years of age or older, and meet the local/state frailty requirements for nursing home admission. Because we are value based, we can surround the participant with services not usually found or easily available in the fee for service world, and thus help frail elders age safely in the community. PACE provides adult day center socialization and meals, therapies (OT, PT, Recreation, Speech), social work, transportation, mental health, pharmacy, primary care and palliative care, to name just a few of the services. The PACE model is predicated on the interdisciplinary team, which makes medical as well as functional decision with the participant.
Our Primary Care Physician positions are ambulatory, full time Monday thru Friday with home based call that is shared. There are 5-10 face to face visits per day, some medically based, some regulatory based (we have to see participants every 6 months for an assessment and care plan). There are family meetings, care planning meetings, review of potential enrollees, some nursing home work (while all of our participants qualify for nursing home care, only about 11% at any one time reside in a skilled nursing facility) involved.