PACE IDT Coordination with Salesforce

The Challenge

Every PACE participant has a team of 11 disciplines behind them, from primary care and nursing to social work, therapy, and transportation. CMS expects that team to know what's happening with each participant and to act when something changes.

In practice, the information that team needs lives everywhere. Here's what IDTs are up against:

Events That Go Unflagged

Let's say a participant falls at home, and another lands in the ER over the weekend. When those events live in disconnected notes, nobody may see them until the next scheduled huddle. By then, the 48-hour discharge review window has often closed...and the care plan revision that could have prevented the next hospitalization didn't happen on time.

Slow Data Sources

Claims data can trail an ER visit or hospitalization by days or weeks. Teams that wait on it will always learn about critical events late.

No Shared View

Care plan and care team information is scattered across spreadsheets and notes. Each discipline sees only one piece of the participant's story.

Huddle Prep Eats the Day

Every hour an IDT lead spends gathering updates for a huddle is an hour taken away from reassessments and care plan revisions. As enrollment grows faster than staff, that tradeoff gets worse.

The Solution

The goal is to get the right information to the right IDT members right away, so the team can spend its time on participants.

Here's how we build it:

Alerts From the Right Source

Automated Flows in Health Cloud watch hospital admission, discharge, and transfer (ADT) data. ER visits and hospitalizations get flagged as soon as they're recorded, so the 48-hour discharge review clock starts right away. Falls and other at-home incidents are captured the moment home care or day center staff report them. Either way, IDT members get notified automatically.

One Shared Participant View

Health Cloud care plan and care team objects give every IDT role the same view of each participant's medical, functional, and psychosocial status. Nursing sees what social work sees and primary care sees what therapy sees.

Low-Prep Huddle Dashboards

Lightning pages or CRM Analytics dashboards pull participant status, flagged events, and pending care plan actions into one view for the daily huddle without the need to prep spreadsheets.

Cross-Role Task Tracking

Huddle decisions become tracked action items assigned to specific disciplines. If something is about to slip, automated escalation catches it.

Audit-Ready Documentation

Field history tracking and structured care plan documentation create a time-stamped record of every event, reassessment, and care plan change. That record supports CMS oversight of your IDT's reassessment and discharge review cadence.

The Results

Faster Response, Lighter Prep, Cleaner Audits

With one connected platform, your IDT finds out about critical events when they happen. ER visits and hospitalizations show up as soon as hospital data records them. Falls show up as soon as staff report them. The 48-hour discharge review clock starts on time, and the team gets the full window to act.

Daily huddles get easier too. Dashboards help IDT leads walk into the meeting ready to make decisions. Those decisions are associated with tracked tasks, so team members are held accountable.

When CMS reviews your reassessment cadence, the record is already there. Every event, every reassessment, and every care plan change has a time stamp.

Most importantly, your team can keep participants stable and caseloads manageable as enrollment grows.

Ready to Keep Your Whole IDT Informed?

PACE enrollment is growing, and your IDT can't afford to learn about a hospitalization days after it happens. Let's look at your center's current process and talk through where a shared, up-to-date view of every participant would help most.