Health Assessments

Regularly assessing the health of the seniors enrolled in PACE is a critical part of the Program of All-inclusive Care for the Elderly.

As part of the enrollment process for joining a PACE program as well as throughout your time as a participant, your healthcare team will conduct regular health assessments. The information is used to develop and update your personalized care plan.  

Initial Assessment
For each person who considers enrolling in the program, at least eight members of your InnovAge interdisciplinary care team, or IDT, complete an initial assessment. The assessment is comprehensive and can include:

• Physical and cognitive function and ability;
• Medication use;
• Participant and caregiver preferences for care;
• Socialization and availability of family support;
• Current health status and treatment needs;
• Nutritional status;
• Home environment, including entrances and exits;
• Participant behavior;
• Psychosocial status;
• Medical and dental status; and
• Participant language and cultural needs.

Semiannual Reassessment
Every six months, at a minimum, each participant has a reassessment completed by members of your care team. These can include your primary care physician, an RN, a social worker, and a recreational therapist or activity coordinator. Other members of your care, or other healthcare professionals involved in providing your care, may also participate in your six-month assessments. 
 
The purpose of your semiannual assessment is to check in on your goals and health status. Your care team will then update or change your personal care plan as needed.

Unscheduled Health Reassessments
Other assessments may happen if a participant has a significant health change or if a participant or their designated representative (such as a family caregiver with medical power of attorney) believes the participant should start, stop, or continue a specific medical service. There are prescribed timeframes and guidance around how these unscheduled health assessments are performed.

For More Information
The Centers for Medicare & Medicaid Services, or CMS, has federal guidelines for PACE providers like InnovAge related health assessments. How they are conducted, when, and which members of the care team are involved, are all outlined by CMS. More information on the role of the IDT, assessments, and care planning is available on the CMS website. Clicking this link will take you to the CMS website and you will leave InnovAge’s website.

Please note that InnovAge PACE participants must receive all needed healthcare, including primary care and specialist physician services (other than emergency services) from InnovAge or a person or company authorized by InnovAge. InnovAge PACE participants may be fully and personally liable for the costs of any out-of-network services.

Page Updated 10/19/23