Care Delivery
PACE
Service Offering Playbook
Care Delivery
Once you have signed a client on for care, it is important that you understand how to now deliver high quality care to that client. There are a number of factors to take into consideration when it comes to care delivery including have a detailed care plan, training caregivers effectively, and receiving payment for services provided. In this section, we will go into detail on these topics to help you understand how to provide high quality care to seniors.
Care Planning
Care plans are created by PACE prior to them reaching out to you to identify whether you have the capacity to take on the veteran client or not. The overall process of onboarding the client should be no different other than it is important to take the time to understand how the Veteran’s care plan is typically different. An example of this difference comes in the form of many of these clients having a higher percentage of PTSD.
Change in Care Plans
Because PACE creates the original care plan, it’s important to ensure that any changes in the condition of the clients are communicated with PACE. Doing so will both show PACE that you are providing quality care, communicating effectively, and it may prompt additional hours of care and/or community resources for that client. Anytime there is a “change of condition” like any other client we inform the VA as that may prompt additional hours of care and/or other community resources.
Training Staff
Having a detailed and effective care plan is going to ensure your staff are clear on what a client needs in order to be effectively cared for during their time at the home. As a business owner, you want to ensure that your caregivers are also trained in providing high quality care for your clients. Being able to adequately explain how your caregivers are trained is going to help the client and family members feel comfortable with having caregivers come into the home to provide care.
There are a number of resources you can look at and use when it comes to training caregivers. As an example, training platforms such as Relias have multiple courses that caregivers can complete in order to be well-versed in any type of care that a client may require. Here are some areas of specialized training that can be valuable for caregivers:
● Military Culture and Veteran-Specific Needs - Caregivers should receive education and training about military culture, the unique experiences and challenges faced by veterans, and the potential impact of service-related conditions such as post-traumatic stress disorder (PTSD), traumatic brain injury (TBI), or physical disabilities. This training can help caregivers better understand and empathize with the some of the seniors they are caring for.● Mental Health Support: Many seniors may struggle with mental health issues such as depression, anxiety, or PTSD. Caregivers can benefit from training in recognizing signs and symptoms of mental health conditions, providing emotional support, and implementing strategies to promote psychological well-being.● Physical Disabilities and Assistive Devices: Seniors may have physical disabilities or injuries that require specialized care. Caregivers should receive training in assisting with mobility, transfers, and the use of assistive devices such as wheelchairs, walkers, or prosthetics. This training helps ensure safe and effective assistance while promoting the veteran's independence.● Medication Management: Seniors often have complex medication regimens. Caregivers should be trained in medication management, including proper administration, dosage tracking, potential side effects, and communication with healthcare providers. Understanding medication interactions and adherence is crucial for promoting an individual’s health and well-being.● Communication and Active Listening: Effective communication is vital in providing quality care to seniors. Caregivers should be trained in active listening techniques, understanding non-verbal cues, and adapting communication styles to meet the unique needs of each client. This training helps establish rapport, build trust, and enhance the caregiver-veteran relationship.● End-of-Life and Palliative Care: Clients nearing the end of life may require specialized care and support. Training in end-of-life care, pain management, grief counseling, and the emotional needs of seniors and their families can help caregivers provide compassionate and dignified care during this sensitive time.
Caregiver training programs are available through various sources, including community organizations, healthcare providers, and online training platforms. The specific training requirements may vary depending on the state, agency, or program. Have open communication with your caregivers on what they feel they may need support or training in as it relates to caring for veterans so they feel they have the tools and resources necessary to provide high quality care.
Beginning Services
Starting in-home care services for a new client requires careful planning and sensitivity to the client's needs. It is a transition for a client to have someone coming into their home and this can create nervousness, anxiety, and fear for the client and their family. Having a strong process in place to alleviate these feelings will provide a stronger brand experience for everyone involved. Here are some of the best practices related to beginning service for a new client:
1. Involve the Family - Work closely with the family or other close support persons to gather detailed information about the client's lifestyle, preferences, routines, and medical history.2. Gradual Introduction – If needed, start with short visits to allow the client to become comfortable with the caregiver. Gradually increase the duration of care as the client becomes more accustomed to the caregiver's presence.3. Consistent Caregivers - Try to maintain consistency with caregivers, as changing caregivers often can be confusing and stressful for individuals4. Clear Communication - Ensure clear communication about the roles and responsibilities of caregivers. Make sure the client and their family understand what to expect.5. Reference the Care Plan – The care plan has been developed to be focused on the client’s needs. Ensure the care plan is being referenced regularly to address a client’s medical needs, personal preferences, daily routines, cognitive challenges, and social and emotional needs.6. Establish a Routine – Having someone come into the home can create stress and clients often do well with a predictable routine. Establish a daily schedule for meals, medication, activities, and rest.7. Prepare for Changes - Care plans must be flexible and adapt to changing needs over time. Regularly assess the client's condition and adjust the care plan as necessary.8. Address Emotional Needs - The transition to in-home care can be emotionally challenging for both the client and their family. Provide emotional support and reassurance throughout the process.9. Be Patient – Caring for any client can be very challenging. Be patient with the challenges that come up and coach your caregivers to have patience. This can help both the client and the family members to remain calm during a very emotionally trying time.
Putting focus on the steps above helps to provide a client and their family members with a brand experience that exemplifies the 360 Approach. Not only are you and your caregivers ensuring high quality care is being delivered for the client but you are also focused on ensuring the family receives what they need for their peace of mind.
Invoicing Services
Invoicing for services provided to PACE participants typically follows the contract guidelines established between the home care agency and the PACE organization. Although the specific invoicing process may vary depending on the individual PACE organization, here are some general steps:
1. Provide Services: The home care agency provides the agreed-upon services to PACE participants.2. Document Services: Document all services provided to each participant, including dates, times, duration, nature of service, and the specific caregiver who provided the service. The agency may also need to document the participant's condition or response to the service.3. Prepare Invoice: The agency prepares an invoice based on the contract terms. This typically includes detailed information about each service provided. The invoice should match the service logs or documentation.4. Submit Invoice: The agency submits the invoice to the PACE organization. The method of submission (e.g., email, mail, electronic health record system, or a designated online portal) will depend on the PACE organization's requirements.5. Follow Up: The agency may need to follow up with the PACE organization to ensure the invoice has been received and is being processed. If there are any issues or discrepancies, the agency will need to address them promptly.6. Receive Payment: Once the invoice has been processed, the agency will receive payment according to the terms of the contract.
Example from the field: In San Diego, the Third-Party administrator for PACE is PEAK TPA. Invoices are submitted in an Excel spreadsheet and uploaded into PEAK’s URL. PEAK reviews, informs PACE that the invoice looks good, PACE signs off and a check is sent to Qualicare San Diego. Every PACE will be different but PEAK TPA is quite common.
Remember that providing services to a PACE participant requires ongoing communication with the PACE organization. The PACE team coordinates all of the participant's care, so the home care agency will need to keep the PACE team informed about the participant's condition and any changes in their needs or services.
Finally, keep in mind that all services provided must be in line with the participant's individual care plan as developed by the PACE team. Services not included in the care plan may not be covered by the PACE organization.
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