PACE
Education and Training
START DEMO
about
Welcome to the Scolari Consulting Demo Course! Our goal is to develop practical, PACE-focused training solutions designed to strengthen operations, support staff readiness, and ensure regulatory compliance across PACE organizations. All courses are developed by a network of experienced PACE Subject Matter Experts (SMEs) with deep operational expertise. In addition:- Training is designed by PACE operators for PACE operators, reflecting real-world workflows, challenges, and decisions.
- Lessons provide practical, day-to-day PACE center examples, including best practices and common pitfalls.
- The focus is on helping teams deliver participant-centered care while maintaining regulatory compliance.
- Courses are interactive and time-efficient, allowing staff to complete training quickly without sacrificing depth or quality.
- Include knowledge checks and applied scenarios to reinforce learning and ensure retention.
- Content is continuously updated to reflect evolving PACE regulations and guidance.
- Courses can be customized to align with each organization’s policies and procedures, keeping programs relevant and audit-ready.
Click to Start Audio
Onboarding Essentials Level 1 & 2
A strong start for every team member.
The Onboarding Essentials learning path provides a structured, two-level introduction to the PACE model of care—helping new hires and returning staff understand not only what PACE is, but how it truly works.Developed by PACE operators and subject matter experts, this series brings the philosophy, structure, and regulatory foundation of PACE to life through real-world examples, practical workflows, and compliance-focused scenarios.
- Level 1: PACE Fundamentals introduces the purpose, mission, and daily rhythm of the PACE model—how interdisciplinary teamwork, communication, and person-centered care come together to keep participants safe and independent.
- Level 2: Compliance Fundamentals builds on that base, translating PACE regulations into practical actions every staff member must know to stay compliant and audit-ready.
Because time matters, each module is designed to be comprehensive, interactive, and accessible, with knowledge checks and scenario-based reflections that reinforce understanding and accountability.By the end of this pathway, learners not only know the PACE model—they understand how to live it in their daily practice.
Click to Start Audio
Module 1
Introduction to PACE
LEarning Objectives
Click on each item to learn why it matters
After completing this module, contractors will be able to:
Describe the PACE model and who it serves.
Explain how care is coordinated through the IDT and Plan of Care.
Identify the contractor’s role, responsibilities, and limitations within PACE.
MODULE 1
Introduction to PACE
Having Technical Issues?Click me
Why This Matters
Click on each item to learn why it matters
Contractors are a critical extension of the PACE care model. Even when services are brief or task-specific, contractor actions directly affect participant safety, care coordination, and regulatory compliance. This module establishes:
Clear Boundaries
Communication Expectations
Non-negotiable Rules
MODULE 1
Introduction to PACE
Having Technical Issues?Click me
Key Definitions
Click on each item to learn why it matters
A comprehensive care model that coordinates all medical and social services for eligible older adults to help them remain safely in the community.
PACE (Program of All-Inclusive Care for the Elderly)
A care team responsible for assessing needs, approving services, and managing the participant’s care plan.
Interdisciplinary Team (IDT):
The authorized document outlining what services are approved, how often they occur, and who provides them.
Plan of Care (POC):
An external service provider delivering authorized services on behalf of PACE.
Contracted Provider (Contractor):
MODULE 1
Introduction to PACE
Having Technical Issues?Click me
What PACE Is
Click on each item to learn why it matters
PACE is a coordinated, all-inclusive care program designed for older adults who:
Are 55 years or older
Meet nursing-home level of care
Live within the designated service area
Can remain safely in the community with PACE support
PACE Mission
To help medically fragile older adults remain healthy, stable, and independent in their homes and communities by replacing fragmented care with one coordinated system.
MODULE 1
Introduction to PACE
Having Technical Issues?Click me
How PACE Works
Click on each item to learn why it matters
PACE delivers care through one unified system, not separate or independent services.
All-Inclusive Service Model Includes:
Role of the IDT:
The IDT:
- Assesses participant needs
- Approves and updates the Plan of Care
- Coordinates all services
- Reviews safety risks and changes in condition
Important: The IDT is the only body authorized to approve, change, or discontinue services.
- Primary and specialty medical care
- Rehabilitative therapies
- Home and personal care
- Transportation
- Adult day center services
- Social work and behavioral health
- Nutrition services
- Durable medical equipment
- Hospital and nursing facility coordination
MODULE 1
Introduction to PACE
Having Technical Issues?Click me
Contractor Integration
Click on each item to learn why it matters
What Contractors MUST NOT Do
What Contractors MUST Do
Change the Plan of Care.
Deliver services exactly as authorized.
Add, reduce, or substitute services.
Follow all PACE policies and instructions.
Make independent care decisions.
Communicate in real time with PACE.
Report refusals, safety issues, and concerns immediately.
Delay reporting issues.
Ignore refusals or changes in condition.
Document accurately and on time
Substitute staff without PACE approval.
Respect participant rights at all times.
Serve as the “eyes and ears” of the IDT in the field.
MODULE 1
Introduction to PACE
Having Technical Issues?Click me
Participant Profile
Click on each item to learn why it matters
PACE participants are typically:
Frail and medically complex.
Living with multiple chronic conditions.
Experiencing cognitive impairment or dementia.
At high risk for hospitalization.
Dependent on consistent, reliable services.
Click to Learn Why It Matters
MODULE 1
Introduction to PACE
Having Technical Issues?Click me
Documentation & Coordination
Click on each item to learn why it matters
PACE relies on timely, accurate communication to keep participants safe and compliant with regulatory requirements.
Contractor Responsibilities
Your Rolein the System
MODULE 1
Introduction to PACE
Having Technical Issues?Click me
Best Practices
Click on each item to learn why it matters
Follow the Plan of Care exactly as written.
Report concerns immediately — even if they seem minor.
Communicate clearly and professionally.
Document facts, not interpretations.
Ask PACE when unsure instead of assuming.
MODULE 1
Introduction to PACE
Having Technical Issues?Click me
Common Errors & How to Avoid Them
Click on each item to learn why it matters
Common Error
How to Avoid Them
Modifying services at participant request
Report the request to PACE; do not change services.
Waiting to report refusals
Report the same day.
Assuming another provider already reported
Always report what you observe.
Making independent decisions
Defer all decisions to the IDT.
Delayed documentation
Submit documentation promptly and accurately.
MODULE 1
Introduction to PACE
Having Technical Issues?Click me
Workflow:Contractor Decision Path
Click on each item to learn why it matters
Review the authorized Plan of Care.
Deliver services as written.
Observe participant and environment.
Identify any refusal, concern, or barrier.
Notify PACE immediately.
Document facts as instructed.
Cooperate with IDT follow-up.
MODULE 1
Introduction to PACE
Having Technical Issues?Click me
Quick Reference:Must Report to PACE
Click on each item to learn why it matters
Service refusals
Changes in condition
Safety hazards
Barriers to service delivery
Participant concerns or complaints
Anything that prevents safe, authorized care
Contractors do not manage care, they support a coordinated system. Following the Plan of Care, reporting in real time, and respecting role boundaries protects participants, contractors, and the PACE program.
MODULE 1
Introduction to PACE
Having Technical Issues?Click me
Module 1Completed!
Click to Start Audio
Key Takeaways:
- PACE is an all-inclusive, coordinated care model for medically fragile older adults.
- Contractors support care delivery but do not make care decisions.
- Following the Plan of Care and reporting concerns in real time is mandatory.
role specifictraining paths
Turning compliance into daily practice — with absolute role clarity.
The Role-Specific Training Paths are designed for key disciplines within the Interdisciplinary Team (IDT)—from PCPs to RNs, MSWs to PTs and RDs. Built by PACE subject matter experts, each path connects regulatory standards to the specific responsibilities, documentation, and decisions each role performs in daily operations.
At the core of this series is role clarity—helping every team member understand not only what their duties are, but why they matter within the PACE model. Clear boundaries and shared understanding strengthen teamwork, reduce duplication, and ensure accountability across the IDT.
Courses blend scenario-based learning, documentation examples, and workflow simulations, guiding staff to recognize risks, apply best practices, and communicate effectively across disciplines.
Each module brings PACE regulations to life, turning them into actionable skills that improve care quality, reduce errors, and uphold participant-centered values.
The result: a confident, compliant team that works together with clarity, purpose, and precision—every day, with every participant.
Click to Start Audio
Module 1
Registered Nurse (RN)Role Overview & Daily Practice
A New Day Begins
Click on each item to learn why it matters
It’s 7:00 a.m. Mindy, a seasoned RN in the PACE program, takes a quiet sip of coffee as she reviews her schedule for the day.
Click on each item in Mindy’s schedule to learn why it matters.
Wound care isn’t just a task—it’s an opportunity for holistic assessment. While cleaning and dressing the wound, you’re also checking circulation, healing progress, and pain levels. You educate the participant and their caregiver, preventing infection and unnecessary hospitalizations.
The Interdisciplinary Team (IDT) huddle is where real coordination happens. It’s your moment to bring in clinical updates, share red flags, and advocate for changes in the care plan. As the RN, your input ensures care decisions are timely, relevant, and person-centered.
Home visits reveal what the clinic can’t—fall risks, hygiene, nutrition, and med adherence. You might catch early red flags like unopened mail or caregiver fatigue. It’s about trust, safety, and seeing the full picture.
Care Planning Huddle with the IDT
Wound Dressing at the Center
A Home Visit
Click to Start Audio
MODULE 1
RN Role Overview & Daily Practice
Having Technical Issues?Click me
A New Day Begins
Click on each item to learn why it matters
You shift between home visits, emergencies, and charting—balancing real-time care with long-term planning.
You pivot
You’re not alone. You co-create care with the IDT, participants, and caregivers—every insight helps shape outcomes.
You collaborate
You guide participants, support families, mentor peers, and speak up when something’s off. Leadership shows in moments big and small.
You lead
You’re the clinical anchor. Your vigilance and follow-through prevent crises and keep care plans running smoothly.
Keep participants safe—and the care system flowing
MODULE 1
RN Role Overview & Daily Practice
Having Technical Issues?Click me
your role in action
Click on the videoto learn why it matters
“Clinical Connector”
You tie it all together You bring participant observations to the IDT, shaping a care plan that reflects real-time needs.
“You Notice Early”
Missed appointments or a tired smileIt could signal depression, illness, or caregiver burnout. You spot changes before they become crises.
“Whole-Person Observation”
It’s more than vitals You assess emotional tone, mobility, safety risks, and social support—every encounter matters.
MODULE 1
RN Role Overview & Daily Practice
Having Technical Issues?Click me
what you actually do
Click on each item to learn why it matters
Assessments
chronic conditions
Initial, semi-annual, and change-in-condition assessments are the backbone of care. They inform the care plan, shape IDT decisions, and track participant progress over time.
You stay ahead of issues like hypertension, diabetes, and fall risk—tracking trends, noticing red flags, and preventing escalation.
care transitions
care plan updates
You ensure smooth handoffs from hospital to home, SNF to Day Center—making sure no detail is lost and no risk goes unnoticed.
What you learn on visits and in conversations directly informs updates to nursing interventions and IDT plans.
Click to Start Audio
MODULE 1
RN Role Overview & Daily Practice
Having Technical Issues?Click me
best practices
Click on each item to learn why it matters
Build Trust
Start with presence.
A calm tone, remembering details, or simply listening can open the door to honesty and better care.
make eye contact
It communicates that you see the person—not just the symptoms.
It helps participants feel safe, heard, and respected.
ask the follow-up question
“How have things been at home?”
“What’s been on your mind lately?”
One thoughtful question can uncover barriers or changes that go far beyond vitals.
MODULE 1
RN Role Overview & Daily Practice
Having Technical Issues?Click me
Documentation:Care Coordination in Action
Click on each item to learn why it matters
Care Action
What you did.
Example: “Contacted PCP”
Clear Observation
What you saw or heard.
Example: “+2 edema in ankles”
Collaborative Next Steps
What’s next and who’s involved.
Example: “Diuretic adjusted; will follow up in 48 hrs”
Clinical Interpretation
What it could indicate.
Example: “Likely fluid retention”
Click to Start Audio
MODULE 1
RN Role Overview & Daily Practice
Having Technical Issues?Click me
RED FLAGS
Click on each item to learn why it matters
Inside Mr. Taylor’s Living Room
Pill Organizer (Full)
Non-adherence to Meds: Missed doses may indicate cognitive decline, depression, or lack of support. Act before it leads to ER visits.
Participant’s Hands (Trembling)
Unsteady Hands: Could suggest neurological issues, medication side effects, or weakness. Ask questions and observe closely.
Bedside or Recliner Area
Changes in Sleep or Appetite: Sleep issues, missed meals, or changes in routines are often early signs of physical or emotional health decline.
Doorway or Calendar
Missed Day Center Visits: Missing routine check-ins may signal depression, transportation issues, or caregiver burnout.
Caregiver in the Background
Caregiver Stress or Withdrawal: Look for silence, irritability, or lack of engagement—these are signs the caregiver needs support too.
MODULE 1
RN Role Overview & Daily Practice
Having Technical Issues?Click me
mistakes that hurtAND HOW TO AVOID THEM
Click on each item to learn why it matters
Document right after each encounter. Timely notes reduce errors and support care continuity.
Use your checklist—even for short visits. You never know what small risk could become a big problem.
Confirm or report it. When in doubt, escalate concerns to the IDT or supervisor.
Assumed Someone Else Would Follow Up
Delayed Documentation
Skipped a Full Assessment
Click to Start Audio
Why it matters:
Good notes guide great care—
and prevent audit issues down the line.
MODULE 1
RN Role Overview & Daily Practice
Having Technical Issues?Click me
Real-Life StoryGloria’s Turning Point
Click on the item to learn why it matters
Mindy trusted her instinct, acted on it, and documented with clarity
Title
What changed the outcome?
Use this side to give more information about a topic.
Subtitle
MODULE 1
RN Role Overview & Daily Practice
Having Technical Issues?Click me
Instruction:Drag the Word
question 1
(3)
(1)
(4)
(5)
(2)
Click for clues
MODULE 1
RN Role Overview & Daily Practice
Having Technical Issues?Click me
Instruction:Multiple Choice
question 2
MODULE 1
RN Role Overview & Daily Practice
Having Technical Issues?Click me
Instruction:Arrange the Sequence
question 3
*Click and drag to arrange in the correct order
Having Technical Issues?Click me
pace edgemicrolearning series
Addressing real challenges. Building lasting habits.
The PACE Edge Microlearning Series transforms real-life operational and compliance challenges into short, actionable learning moments that drive immediate improvement.
Each lesson tackles issues that commonly hinder operations or compliance—from documentation lapses to coordination gaps or follow-up delays—and shows staff how to prevent them before they escalate.
Developed by PACE operators and instructional designers, these micro-courses deliver practical insights, best practices, and red-flag reminders that staff can apply immediately to improve daily performance.
Released quarterly, the series keeps learning fresh and relevant while reinforcing key behaviors throughout the year.
The goal is simple: to build a culture of continuous learning where small lessons lead to stronger teams, better outcomes, and consistent, participant-centered care.
Click to Start Audio
What are SMART Goals?
Why do they matter in PACE?
OBJECTIVES
Click on each item to learn why it matters
First Objective
Identify common compliance issues in vague or non-SMART care plan goals using real PACE examples.
Second Objective
Rewrite non-compliant goals into SMART-aligned statements that are measurable, time-bound, and participant-centered.
Third Objective
Apply the SMART goal-writing formula to create clear, defensible goals that meet 42 CFR §460.106 requirements.
Having Technical Issues?Click me
SMALL SMART GOALS
Click on each item to learn why it matters
In PACE, care plan goals don’t need to be big or dramatic — they need to be clear, doable, and documented well.
Example: Big → Small
Example
Why Small Goals MatterWhen a goal is too broad — like “Improve strength” or “Eat better” —
it’s hard to track, hard to implement, and nearly impossible to audit.
Example
“Margaret will transfer from bed to chair 2x/day with one-person standby assist using walker over the next 30 days.”
“Margaret will not fall again.”
SMARTSmall Goal
TOO BROAD
But when you break a big idea into a small, SMART goal, you get:
Clarity on what needs to happen
Team alignment on how to support it
It’s not dramatic.
A better chance of achieving something meaningful
But it’s clear, realistic, and audit-proof.
Having Technical Issues?Click me
quick guide
Click on each item to learn why it matters
Writing Small SMART Goals
“Jose will use a pre-filled med box and receive daily AM reminders from home care staff for 30 days.”
“Jose will manage his medications better.”
ORIGINAL
SMART
Click to Start Audio
Having Technical Issues?Click me
examples
Click on each item to learn why it matters
SMART Goal:
SMART Goal:
SMART Goal:
SMART Goal:
SMART Goal:
“Participant will consume at least 75% of served lunch and dinner meals for 14 consecutive days, monitored by center staff.”
“Participant will take AM medications within 1 hour of scheduled time for 21 days, with prompts from home care aide.”
“Participant will attend at least 3 of 4 scheduled specialty appointments this month using escorted transport with known driver.”
“Participant will attend the PACE day center 2x/week for 30 days and engage in at least one group activity per visit.”
“Participant will complete 15 minutes of supervised balance training with PT 3x/week for 4 weeks.”
Nutrition & Weight Loss
Medication Adherence
Depression& Isolation
Transportation & Appointments
Falls & Mobility
“Participant will attend all medical appointments.”
“Participant will be more compliant with medications.”
“Participant will eat more.”
“Participant will feel less lonely.”
“Participant will improve balance.”
Having Technical Issues?Click me
SMART GOAL FORMULA
Click on each item to learn why it matters
SMART Goal Formula
[Participant name] will [action verb] [specific task or outcome] with [level of support or conditions] [frequency or duration], for [# of days/weeks], in order to [desired measurable result].
Example
This formula helps PACE teams write goals that:
Example Using the Formula:Margaret will transfer from bed to chair
with one-person standby assist,
2x/day,
for 30 days,
in order to reduce fall risk and maintain safety.
Are audit-ready under 42 CFR §460.106
Include measurable outcomes and realistic timeline
Can be tracked by any member of the IDT
Having Technical Issues?Click me
SMART Goals Evaluation
Read Carefully
Instruction:True or False
question 1
Having Technical Issues?Click me
Instruction:Arrange the Sequence
question 2
*Click and drag to arrange in the correct order
Having Technical Issues?Click me
Instruction:Multiple Choice
question 3
Having Technical Issues?Click me
Instruction:Drag the Word
question 4
Having Technical Issues?Click me
Instruction:Arrange the Sequence
question 5
*Click and drag to arrange in the correct order
Having Technical Issues?Click me
Customizable to Your Program’s Day-to-Day Operations
Every PACE organization operates within its own structure, workflows, and policies — which is why our courses are designed to be customized to reflect your real-world operations.We align each training to your policies and procedures (P&Ps), internal forms, communication workflows, and participant care processes. This ensures that staff don’t just learn general concepts — they learn how to apply them within your specific operational context.Customization may include:- Integrating your SOPs, documentation standards, and internal forms directly into the lessons.
- Adapting case examples and scenarios to mirror your participant profiles and team workflows.
- Delivering all courses as SCORM-compliant files, ready for upload into your existing LMS .
- Embedding your program’s branding, terminology, and process visuals for a seamless learner experience.
- Including program-specific audit insights, best practices, and compliance reminders.
Whether used as-is or fully tailored, each course delivers practical, relevant training that mirrors your day-to-day operations, reinforces compliance, and strengthens participant-centered care.
Click to Start Audio
Any questions?
rosana.scolari@scolariconsulting.com www.scolariconsulting.com
Reminder
You don’t have to write a “perfect” goal. You just have to write a clear one that supports the participant and reflects real-world IDT care.
Why it Works:
- Realistic expectation (not “all” appointments)
- Includes support strategy (known driver, escorted)
- Time-limited (this month)
- Allows IDT to track progress with clear threshold
Why it Works:
- Quantifies “more”
- Creates a baseline for progress tracking
- Connects goal to monitoring responsibility
- Ensures outcome is documentable in EMR
Why it Works:
- Tracks adherence by time
- Includes staff role in support
- Limits timeframe (21 days)
- Directly aligns with common audit focus on medication compliance
Why it Works:
- Specific action (balance training)
- Measurable time and frequency
- Achievable within PT scope
- Relevant to fall risk
- Time-bound to 4 weeks
Why it Works:
- Addresses behavioral activation
- Gives a trackable frequency and timeframe
- Outcome tied to mental health support plan
- Measurable, relevant, and documented easily
Your Role in the System
Contractors are often the first to notice:
- Changes in condition
- Safety hazards
- Behavioral changes
- Environmental risks
Your reporting allows the IDT to intervene early.
Contractor Responsibilities
- Communicate barriers to service delivery immediately
- Report refusals and concerns the same day
- Provide factual, objective information
- Avoid assumptions or opinions in documentation
Why This Matters
Small changes in condition, environment, or behavior can quickly become medical or safety emergencies.
Updated - Scolari Consulting_DEMOApr2026
Scolari Consulting
Created on March 27, 2026
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Transcript
PACE
Education and Training
START DEMO
about
Welcome to the Scolari Consulting Demo Course! Our goal is to develop practical, PACE-focused training solutions designed to strengthen operations, support staff readiness, and ensure regulatory compliance across PACE organizations. All courses are developed by a network of experienced PACE Subject Matter Experts (SMEs) with deep operational expertise. In addition:- Training is designed by PACE operators for PACE operators, reflecting real-world workflows, challenges, and decisions.
- Lessons provide practical, day-to-day PACE center examples, including best practices and common pitfalls.
- The focus is on helping teams deliver participant-centered care while maintaining regulatory compliance.
- Courses are interactive and time-efficient, allowing staff to complete training quickly without sacrificing depth or quality.
- Include knowledge checks and applied scenarios to reinforce learning and ensure retention.
- Content is continuously updated to reflect evolving PACE regulations and guidance.
- Courses can be customized to align with each organization’s policies and procedures, keeping programs relevant and audit-ready.
Click to Start Audio
Onboarding Essentials Level 1 & 2
A strong start for every team member.
The Onboarding Essentials learning path provides a structured, two-level introduction to the PACE model of care—helping new hires and returning staff understand not only what PACE is, but how it truly works.Developed by PACE operators and subject matter experts, this series brings the philosophy, structure, and regulatory foundation of PACE to life through real-world examples, practical workflows, and compliance-focused scenarios.
- Level 1: PACE Fundamentals introduces the purpose, mission, and daily rhythm of the PACE model—how interdisciplinary teamwork, communication, and person-centered care come together to keep participants safe and independent.
- Level 2: Compliance Fundamentals builds on that base, translating PACE regulations into practical actions every staff member must know to stay compliant and audit-ready.
Because time matters, each module is designed to be comprehensive, interactive, and accessible, with knowledge checks and scenario-based reflections that reinforce understanding and accountability.By the end of this pathway, learners not only know the PACE model—they understand how to live it in their daily practice.Click to Start Audio
Module 1
Introduction to PACE
LEarning Objectives
Click on each item to learn why it matters
After completing this module, contractors will be able to:
Describe the PACE model and who it serves.
Explain how care is coordinated through the IDT and Plan of Care.
Identify the contractor’s role, responsibilities, and limitations within PACE.
MODULE 1
Introduction to PACE
Having Technical Issues?Click me
Why This Matters
Click on each item to learn why it matters
Contractors are a critical extension of the PACE care model. Even when services are brief or task-specific, contractor actions directly affect participant safety, care coordination, and regulatory compliance. This module establishes:
Clear Boundaries
Communication Expectations
Non-negotiable Rules
MODULE 1
Introduction to PACE
Having Technical Issues?Click me
Key Definitions
Click on each item to learn why it matters
A comprehensive care model that coordinates all medical and social services for eligible older adults to help them remain safely in the community.
PACE (Program of All-Inclusive Care for the Elderly)
A care team responsible for assessing needs, approving services, and managing the participant’s care plan.
Interdisciplinary Team (IDT):
The authorized document outlining what services are approved, how often they occur, and who provides them.
Plan of Care (POC):
An external service provider delivering authorized services on behalf of PACE.
Contracted Provider (Contractor):
MODULE 1
Introduction to PACE
Having Technical Issues?Click me
What PACE Is
Click on each item to learn why it matters
PACE is a coordinated, all-inclusive care program designed for older adults who:
Are 55 years or older
Meet nursing-home level of care
Live within the designated service area
Can remain safely in the community with PACE support
PACE Mission
To help medically fragile older adults remain healthy, stable, and independent in their homes and communities by replacing fragmented care with one coordinated system.
MODULE 1
Introduction to PACE
Having Technical Issues?Click me
How PACE Works
Click on each item to learn why it matters
PACE delivers care through one unified system, not separate or independent services.
All-Inclusive Service Model Includes:
Role of the IDT:
The IDT:
- Assesses participant needs
- Approves and updates the Plan of Care
- Coordinates all services
- Reviews safety risks and changes in condition
Important: The IDT is the only body authorized to approve, change, or discontinue services.MODULE 1
Introduction to PACE
Having Technical Issues?Click me
Contractor Integration
Click on each item to learn why it matters
What Contractors MUST NOT Do
What Contractors MUST Do
Change the Plan of Care.
Deliver services exactly as authorized.
Add, reduce, or substitute services.
Follow all PACE policies and instructions.
Make independent care decisions.
Communicate in real time with PACE.
Report refusals, safety issues, and concerns immediately.
Delay reporting issues.
Ignore refusals or changes in condition.
Document accurately and on time
Substitute staff without PACE approval.
Respect participant rights at all times.
Serve as the “eyes and ears” of the IDT in the field.
MODULE 1
Introduction to PACE
Having Technical Issues?Click me
Participant Profile
Click on each item to learn why it matters
PACE participants are typically:
Frail and medically complex.
Living with multiple chronic conditions.
Experiencing cognitive impairment or dementia.
At high risk for hospitalization.
Dependent on consistent, reliable services.
Click to Learn Why It Matters
MODULE 1
Introduction to PACE
Having Technical Issues?Click me
Documentation & Coordination
Click on each item to learn why it matters
PACE relies on timely, accurate communication to keep participants safe and compliant with regulatory requirements.
Contractor Responsibilities
Your Rolein the System
MODULE 1
Introduction to PACE
Having Technical Issues?Click me
Best Practices
Click on each item to learn why it matters
Follow the Plan of Care exactly as written.
Report concerns immediately — even if they seem minor.
Communicate clearly and professionally.
Document facts, not interpretations.
Ask PACE when unsure instead of assuming.
MODULE 1
Introduction to PACE
Having Technical Issues?Click me
Common Errors & How to Avoid Them
Click on each item to learn why it matters
Common Error
How to Avoid Them
Modifying services at participant request
Report the request to PACE; do not change services.
Waiting to report refusals
Report the same day.
Assuming another provider already reported
Always report what you observe.
Making independent decisions
Defer all decisions to the IDT.
Delayed documentation
Submit documentation promptly and accurately.
MODULE 1
Introduction to PACE
Having Technical Issues?Click me
Workflow:Contractor Decision Path
Click on each item to learn why it matters
Review the authorized Plan of Care.
Deliver services as written.
Observe participant and environment.
Identify any refusal, concern, or barrier.
Notify PACE immediately.
Document facts as instructed.
Cooperate with IDT follow-up.
MODULE 1
Introduction to PACE
Having Technical Issues?Click me
Quick Reference:Must Report to PACE
Click on each item to learn why it matters
Service refusals
Changes in condition
Safety hazards
Barriers to service delivery
Participant concerns or complaints
Anything that prevents safe, authorized care
Contractors do not manage care, they support a coordinated system. Following the Plan of Care, reporting in real time, and respecting role boundaries protects participants, contractors, and the PACE program.
MODULE 1
Introduction to PACE
Having Technical Issues?Click me
Module 1Completed!
Click to Start Audio
Key Takeaways:
role specifictraining paths
Turning compliance into daily practice — with absolute role clarity.
The Role-Specific Training Paths are designed for key disciplines within the Interdisciplinary Team (IDT)—from PCPs to RNs, MSWs to PTs and RDs. Built by PACE subject matter experts, each path connects regulatory standards to the specific responsibilities, documentation, and decisions each role performs in daily operations. At the core of this series is role clarity—helping every team member understand not only what their duties are, but why they matter within the PACE model. Clear boundaries and shared understanding strengthen teamwork, reduce duplication, and ensure accountability across the IDT. Courses blend scenario-based learning, documentation examples, and workflow simulations, guiding staff to recognize risks, apply best practices, and communicate effectively across disciplines. Each module brings PACE regulations to life, turning them into actionable skills that improve care quality, reduce errors, and uphold participant-centered values. The result: a confident, compliant team that works together with clarity, purpose, and precision—every day, with every participant.
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Module 1
Registered Nurse (RN)Role Overview & Daily Practice
A New Day Begins
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It’s 7:00 a.m. Mindy, a seasoned RN in the PACE program, takes a quiet sip of coffee as she reviews her schedule for the day.
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Wound care isn’t just a task—it’s an opportunity for holistic assessment. While cleaning and dressing the wound, you’re also checking circulation, healing progress, and pain levels. You educate the participant and their caregiver, preventing infection and unnecessary hospitalizations.
The Interdisciplinary Team (IDT) huddle is where real coordination happens. It’s your moment to bring in clinical updates, share red flags, and advocate for changes in the care plan. As the RN, your input ensures care decisions are timely, relevant, and person-centered.
Home visits reveal what the clinic can’t—fall risks, hygiene, nutrition, and med adherence. You might catch early red flags like unopened mail or caregiver fatigue. It’s about trust, safety, and seeing the full picture.
Care Planning Huddle with the IDT
Wound Dressing at the Center
A Home Visit
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MODULE 1
RN Role Overview & Daily Practice
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A New Day Begins
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You shift between home visits, emergencies, and charting—balancing real-time care with long-term planning.
You pivot
You’re not alone. You co-create care with the IDT, participants, and caregivers—every insight helps shape outcomes.
You collaborate
You guide participants, support families, mentor peers, and speak up when something’s off. Leadership shows in moments big and small.
You lead
You’re the clinical anchor. Your vigilance and follow-through prevent crises and keep care plans running smoothly.
Keep participants safe—and the care system flowing
MODULE 1
RN Role Overview & Daily Practice
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your role in action
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“Clinical Connector”
You tie it all together You bring participant observations to the IDT, shaping a care plan that reflects real-time needs.
“You Notice Early”
Missed appointments or a tired smileIt could signal depression, illness, or caregiver burnout. You spot changes before they become crises.
“Whole-Person Observation”
It’s more than vitals You assess emotional tone, mobility, safety risks, and social support—every encounter matters.
MODULE 1
RN Role Overview & Daily Practice
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what you actually do
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Assessments
chronic conditions
Initial, semi-annual, and change-in-condition assessments are the backbone of care. They inform the care plan, shape IDT decisions, and track participant progress over time.
You stay ahead of issues like hypertension, diabetes, and fall risk—tracking trends, noticing red flags, and preventing escalation.
care transitions
care plan updates
You ensure smooth handoffs from hospital to home, SNF to Day Center—making sure no detail is lost and no risk goes unnoticed.
What you learn on visits and in conversations directly informs updates to nursing interventions and IDT plans.
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MODULE 1
RN Role Overview & Daily Practice
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best practices
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Build Trust
Start with presence. A calm tone, remembering details, or simply listening can open the door to honesty and better care.
make eye contact
It communicates that you see the person—not just the symptoms. It helps participants feel safe, heard, and respected.
ask the follow-up question
“How have things been at home?” “What’s been on your mind lately?” One thoughtful question can uncover barriers or changes that go far beyond vitals.
MODULE 1
RN Role Overview & Daily Practice
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Documentation:Care Coordination in Action
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Care Action
What you did.
Example: “Contacted PCP”
Clear Observation
What you saw or heard.
Example: “+2 edema in ankles”
Collaborative Next Steps
What’s next and who’s involved.
Example: “Diuretic adjusted; will follow up in 48 hrs”
Clinical Interpretation
What it could indicate.
Example: “Likely fluid retention”
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MODULE 1
RN Role Overview & Daily Practice
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RED FLAGS
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Inside Mr. Taylor’s Living Room
Pill Organizer (Full)
Non-adherence to Meds: Missed doses may indicate cognitive decline, depression, or lack of support. Act before it leads to ER visits.
Participant’s Hands (Trembling)
Unsteady Hands: Could suggest neurological issues, medication side effects, or weakness. Ask questions and observe closely.
Bedside or Recliner Area
Changes in Sleep or Appetite: Sleep issues, missed meals, or changes in routines are often early signs of physical or emotional health decline.
Doorway or Calendar
Missed Day Center Visits: Missing routine check-ins may signal depression, transportation issues, or caregiver burnout.
Caregiver in the Background
Caregiver Stress or Withdrawal: Look for silence, irritability, or lack of engagement—these are signs the caregiver needs support too.
MODULE 1
RN Role Overview & Daily Practice
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mistakes that hurtAND HOW TO AVOID THEM
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Document right after each encounter. Timely notes reduce errors and support care continuity.
Use your checklist—even for short visits. You never know what small risk could become a big problem.
Confirm or report it. When in doubt, escalate concerns to the IDT or supervisor.
Assumed Someone Else Would Follow Up
Delayed Documentation
Skipped a Full Assessment
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Why it matters: Good notes guide great care— and prevent audit issues down the line.
MODULE 1
RN Role Overview & Daily Practice
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Real-Life StoryGloria’s Turning Point
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Mindy trusted her instinct, acted on it, and documented with clarity
Title
What changed the outcome?
Use this side to give more information about a topic.
Subtitle
MODULE 1
RN Role Overview & Daily Practice
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Instruction:Drag the Word
question 1
(3)
(1)
(4)
(5)
(2)
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MODULE 1
RN Role Overview & Daily Practice
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Instruction:Multiple Choice
question 2
MODULE 1
RN Role Overview & Daily Practice
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Instruction:Arrange the Sequence
question 3
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pace edgemicrolearning series
Addressing real challenges. Building lasting habits.
The PACE Edge Microlearning Series transforms real-life operational and compliance challenges into short, actionable learning moments that drive immediate improvement. Each lesson tackles issues that commonly hinder operations or compliance—from documentation lapses to coordination gaps or follow-up delays—and shows staff how to prevent them before they escalate. Developed by PACE operators and instructional designers, these micro-courses deliver practical insights, best practices, and red-flag reminders that staff can apply immediately to improve daily performance. Released quarterly, the series keeps learning fresh and relevant while reinforcing key behaviors throughout the year. The goal is simple: to build a culture of continuous learning where small lessons lead to stronger teams, better outcomes, and consistent, participant-centered care.
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What are SMART Goals?
Why do they matter in PACE?
OBJECTIVES
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First Objective
Identify common compliance issues in vague or non-SMART care plan goals using real PACE examples.
Second Objective
Rewrite non-compliant goals into SMART-aligned statements that are measurable, time-bound, and participant-centered.
Third Objective
Apply the SMART goal-writing formula to create clear, defensible goals that meet 42 CFR §460.106 requirements.
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SMALL SMART GOALS
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In PACE, care plan goals don’t need to be big or dramatic — they need to be clear, doable, and documented well.
Example: Big → Small
Example
Why Small Goals MatterWhen a goal is too broad — like “Improve strength” or “Eat better” — it’s hard to track, hard to implement, and nearly impossible to audit.
Example
“Margaret will transfer from bed to chair 2x/day with one-person standby assist using walker over the next 30 days.”
“Margaret will not fall again.”
SMARTSmall Goal
TOO BROAD
But when you break a big idea into a small, SMART goal, you get:
Clarity on what needs to happen
Team alignment on how to support it
It’s not dramatic.
A better chance of achieving something meaningful
But it’s clear, realistic, and audit-proof.
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quick guide
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Writing Small SMART Goals
“Jose will use a pre-filled med box and receive daily AM reminders from home care staff for 30 days.”
“Jose will manage his medications better.”
ORIGINAL
SMART
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examples
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SMART Goal:
SMART Goal:
SMART Goal:
SMART Goal:
SMART Goal:
“Participant will consume at least 75% of served lunch and dinner meals for 14 consecutive days, monitored by center staff.”
“Participant will take AM medications within 1 hour of scheduled time for 21 days, with prompts from home care aide.”
“Participant will attend at least 3 of 4 scheduled specialty appointments this month using escorted transport with known driver.”
“Participant will attend the PACE day center 2x/week for 30 days and engage in at least one group activity per visit.”
“Participant will complete 15 minutes of supervised balance training with PT 3x/week for 4 weeks.”
Nutrition & Weight Loss
Medication Adherence
Depression& Isolation
Transportation & Appointments
Falls & Mobility
“Participant will attend all medical appointments.”
“Participant will be more compliant with medications.”
“Participant will eat more.”
“Participant will feel less lonely.”
“Participant will improve balance.”
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SMART GOAL FORMULA
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SMART Goal Formula
[Participant name] will [action verb] [specific task or outcome] with [level of support or conditions] [frequency or duration], for [# of days/weeks], in order to [desired measurable result].
Example
This formula helps PACE teams write goals that:
Example Using the Formula:Margaret will transfer from bed to chair with one-person standby assist, 2x/day, for 30 days, in order to reduce fall risk and maintain safety.
Are audit-ready under 42 CFR §460.106
Include measurable outcomes and realistic timeline
Can be tracked by any member of the IDT
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SMART Goals Evaluation
Read Carefully
Instruction:True or False
question 1
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Instruction:Arrange the Sequence
question 2
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Instruction:Multiple Choice
question 3
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Instruction:Drag the Word
question 4
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Instruction:Arrange the Sequence
question 5
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Customizable to Your Program’s Day-to-Day Operations
Every PACE organization operates within its own structure, workflows, and policies — which is why our courses are designed to be customized to reflect your real-world operations.We align each training to your policies and procedures (P&Ps), internal forms, communication workflows, and participant care processes. This ensures that staff don’t just learn general concepts — they learn how to apply them within your specific operational context.Customization may include:
- Integrating your SOPs, documentation standards, and internal forms directly into the lessons.
- Adapting case examples and scenarios to mirror your participant profiles and team workflows.
- Delivering all courses as SCORM-compliant files, ready for upload into your existing LMS .
- Embedding your program’s branding, terminology, and process visuals for a seamless learner experience.
- Including program-specific audit insights, best practices, and compliance reminders.
Whether used as-is or fully tailored, each course delivers practical, relevant training that mirrors your day-to-day operations, reinforces compliance, and strengthens participant-centered care.Click to Start Audio
Any questions?
rosana.scolari@scolariconsulting.com www.scolariconsulting.com
Reminder
You don’t have to write a “perfect” goal. You just have to write a clear one that supports the participant and reflects real-world IDT care.
Why it Works:
Why it Works:
Why it Works:
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Your Role in the System
Contractors are often the first to notice:
- Changes in condition
- Safety hazards
- Behavioral changes
- Environmental risks
Your reporting allows the IDT to intervene early.Contractor Responsibilities
Why This Matters
Small changes in condition, environment, or behavior can quickly become medical or safety emergencies.