- Select a PACE participant from the left panel to load their comprehensive care plan.
- Use the colored risk dots (red=high, amber=medium, green=low) to prioritize outreach.
- Navigate between assessment domains using the tab bar at the top of the care plan.
- The compliance badges at the top show overall program health at a glance.
PACE Care Planning
Comprehensive care plans for Program of All-inclusive Care for the Elderly participants
PACE Compliance: 94%
IDT Meeting Current
3 Plans Due for Review
CMS Audit Ready
PACE Participants
47 Active
EM
Eleanor Mitchell
RJ
Robert Johnson
MG
Maria Gonzalez
WC
William Chen
DP
Dorothy Patterson
HL
Harold Lewis
BT
Beatrice Thompson
JM
James Morrison
RW
Ruth Washington
CK
Charles King
EM
Eleanor Mitchell
DOB: 03/12/1938 · Age 86 · PACE ID: P-00142 · Enrolled: Jan 2021
High Risk
Active PACE
Medical
Social
Functional
Cognitive
Nutritional
Spiritual
Care Goals
IDT Team
DHC Schedule
Review Cycle
Primary Diagnoses
CHF (I50.32)Stage III, Systolic
T2DM (E11.9)Uncontrolled
CKD (N18.3)Stage 3
HTN (I10)With Complications
Medications
Furosemide 40mgDaily
Metformin 500mgBID
Lisinopril 10mgDaily
Carvedilol 6.25mgBID
Recent Lab Values
HbA1c8.7% ↑
BNP342 pg/mL
eGFR41 mL/min
BP (Last)128/78 mmHg
Preventive Services
Flu Vaccine✓ Oct 2024
Pneumococcal✓ Mar 2023
Eye ExamDue Jan 2025
Dental CleaningOverdue
Living Situation
ResidencePrivate Home
Lives WithAlone
Primary CaregiverDaughter (Sarah)
Emergency ContactSarah Mitchell
SDOH Factors
Food SecurityStable
TransportationPACE Transport
Social IsolationModerate Risk
Financial StressLow
ADL Assessment
BathingPartial Assist
DressingPartial Assist
ToiletingIndependent
TransferringSupervision
ContinencePartial
FeedingIndependent
IADL Assessment
Medication MgmtDependent
FinancesDependent
ShoppingDependent
HousekeepingPartial Assist
Meal PrepPartial Assist
Cognitive Screening
MMSE Score21/30 (Mild)
Last AssessmentOct 15, 2024
Dementia DxEarly Alzheimer's
Decision MakingIntact with Support
Behavioral Indicators
Wandering RiskLow
AgitationRare
Sleep DisturbanceOccasional
Nutritional Status
MNA Score22/30 (At Risk)
Weight142 lbs
BMI24.1
Diet TypeLow Sodium, Diabetic
Dietary Orders
Sodium<2g/day
Fluid Restriction1.5L/day
TextureSoft/Minced
SupplementEnsure (1x/day)
Spiritual & Cultural Preferences
Religious AffiliationCatholic
Spiritual NeedsChaplain Visits Monthly
Cultural BackgroundIrish-American
LanguageEnglish (Primary)
EOL PreferencesDNR on File
Advance Directive✓ On File (2022)
| Goal | Domain | Measurable Outcome | Target Date | Progress | Status |
|---|---|---|---|---|---|
| Improve glycemic control | Medical | HbA1c <7.5% by review | Mar 2025 | 65% |
In Progress |
| Maintain CHF stability | Medical | No hospitalizations Q1 | Mar 2025 | 80% |
On Track |
| Increase social engagement | Social | 3+ DHC days/week | Ongoing | 90% |
Achieved |
| Improve ADL independence | Functional | Independent bathing by Q2 | Jun 2025 | 30% |
Needs Attention |
| Cognitive engagement | Cognitive | MMSE score ≥22 at 6-month review | Apr 2025 | 50% |
In Progress |
MD
Dr. James Park
Attending Physician
Last note: Today
RN
Sandra Torres, RN
Primary Nurse
Last note: Yesterday
SW
Lisa Chen, MSW
Social Worker
Last note: 3 days ago
PT
Mike Johnson, PT
Physical Therapist
Last note: 1 week ago
OT
Amy Wilson, OT
Occupational Therapist
Last note: 1 week ago
RD
Patricia Kim, RD
Registered Dietitian
Last note: 2 weeks ago
Next IDT Meeting
Thursday, April 10, 2025 at 10:00 AM · Conference Room B
Day Health Center Schedule — Week of Apr 7, 2025
Mon
8:30 AMVitals Check
10:00 AMPT Session
2:00 PMRecreational
Tue
9:00 AMNursing Assessment
11:00 AMGroup Activity
Wed
8:30 AMVitals Check
10:30 AMOT Session
1:30 PMSocial Worker
Thu
9:00 AMIDT Meeting
11:00 AMPT Session
Fri
8:30 AMVitals Check
10:00 AMRecreational
2:00 PMFamily Conference
6-Month Review Cycle — Plan Year 2025
Next formal review due: April 15, 2025
✓
Initial
Jan 2024
✓
6-Month
Jul 2024
!
Annual
Jan 2025
4
6-Month
Jul 2025
5
Annual
Jan 2026
Annual Review Checklist