Indicators for Appropriate Referrals
PACE programs are designed to serve older adults who live in the community. Clients may reside in their own home or with their families, or in licensed residential facilities. We seek to begin providing services prior to the need for 24-hour supervision so that the client can benefit from preventive services in their own homes and enjoy the highest quality of life possible.
The following situations are indicators that an individual may benefit from enrolling at Providence ElderPlace:
- Fragmented medical care and supportive services
- Recent hospitalization due to illness or injury, resulting in decreased function
- Frequent falls
- A degenerative, long-term prognosis that the existing service delivery system has been unable to address
- Non-Medicaid covered needs that can be addressed by the PACE provider, whereby the end result prevents a nursing facility placement (e.g. Occupational Therapy, Physical Therapy, Speech Therapy)
- Socially isolated or living alone with diagnosed dementia
- Missed medical appointments
- Involved in a day health program, but missing attendance days due to medical frailty or other circumstances
- Having difficulties with medication management
- Medically compromised with a diagnosed mental illness
- History of multiple emergency room visits, hospitalizations, or short term nursing home stays
- Unstable or questionable care giver situation, history of APS involvement
- Utilizing the maximum or close to maximum number of personal care hours allowed by Medicaid
- Requiring extensive time commitment by case manager to insure client health & safety
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