Building the IDT Foundation Too Late: The Quiet Risk in New PACE Programs

Opening or expanding a PACE program requires enormous energy. That intensity shows up everywhere at once. Hiring must happen quickly, enrollment goals are pressing, participants need services immediately, and vendors must perform. In the middle of that urgency, organizations often assume the interdisciplinary team will naturally figure out how to make decisions together.

In my experience, the real risk is not building the team too late. It is installing the decision-making foundation too late. Without structure, even excellent professionals fall back on habits learned somewhere else. Those habits do not always translate to PACE.

The Adjustment People Rarely Anticipate

Many staff entering PACE come from settings where external rules created clear boundaries. In a nursing facility, the MDS Coordinator often helped establish what was reasonable and reimbursable. Under Medicare Advantage or traditional Medicare, the plan dictated limits. Under Medicaid, some services simply were not options. Clinicians practiced inside those lanes.

PACE changes the picture. Now the organization is both provider and insurer. The team must evaluate the whole person, determine necessity, manage risk, coordinate disciplines, and remain responsible for finite resources. That is a significant shift in thinking, and it does not happen automatically because someone attended orientation. Nearly every new or expanding program experiences this phase. It reflects the complexity of the PACE model, not a lack of dedication from the people doing the work.

What Usually Happens Early On

When teams are unclear about how determinations should be made within the PACE framework, they tend to fall into predictable patterns. These patterns are rarely intentional. They develop because people are trying to move work forward without a common structure.

The Hard No

Requests are treated simply as requests rather than formal Service Determination Requests requiring full interdisciplinary evaluation. Team members may default to previous experience with other payers and assume that insurance would never cover it, that it falls outside the benefit, or that the organization does not usually provide those services. As a result, assessment depth can vary, required areas may not be fully explored, and documentation may not reflect comprehensive team reasoning. Families experience this as inconsistency. They may say they were told something different, reflecting the common tension between enrollment messaging and clinical determination.

Inside the organization, valuable time shifts toward defending positions rather than aligning around process.

The Open Door

The opposite pattern can emerge just as easily.

Services are approved generously. Teams move quickly. No one wants to appear obstructive or unsupportive. On the surface, this can feel collaborative and participant-centered. But without a disciplined framework, problems build underneath.Requests may be approved before the assessment is fully developed. Additional disciplines may not be pulled in to widen the clinical view. Instead of slowing down to ask what the full picture shows, the team proceeds on partial information.

Most often, staff are trying to avoid conflict. They want to support one another, help the participant, and keep the meeting moving. The easiest path becomes the decision. Again, this is not bad intent. It is human behavior in the absence of clear guardrails. Once a service is in place, it gains momentum. Small daily inconsistencies compound into significant financial patterns over time. If attendance is inconsistent, equipment goes unused, or the support is not solving the problem, the organization must reopen the determination.

That means reassessment, documentation, communication, and often the uncomfortable work of modifying or discontinuing something that already feels promised. Anyone who has done this knows it is always harder to take something back than to slow down before it starts. When patterns of automatic approval develop, the team can gradually lose focus on the central principle of PACE: services are individualized and based on assessed need.

Without a shared decision framework, variation widens, financial pressure increases, and trust across disciplines can erode. Different path. Same destination.

When Leadership Is Not Consistently Present

If leadership is not visible where determinations occur, human nature will simplify the work. Teams may postpone difficult conversations, rely on the most confident voice, repeat fragments remembered from training, or stop opening the regulations altogether.

No one intends to drift. But drift happens.

And in PACE, drift rarely announces itself. It appears gradually in documentation language, in inconsistent service determinations, in meetings that feel longer but less decisive. Over time, variation becomes normalized.

This is why leadership presence inside the interdisciplinary decision process matters so deeply. Without a clearly reinforced framework, even capable teams revert to prior habits. (See: Building the IDT Foundation Too Late.)

What Survey Expectations Require

The expectation is not that every answer is yes. The expectation is that the team can demonstrate how it assessed need, incorporated interdisciplinary judgment, followed process, and documented the rationale. Explaining that another payer would not have covered the service is not a defensible position in PACE. The reasoning must stand on its own.

Survey findings rarely begin during survey week. They develop gradually through everyday variation long before reviewers arrive.

Strong Teams Are Built on Purpose

The good news is that decision discipline can be installed. With consistent leadership presence, clear service determination pathways, defined documentation expectations, and routine reinforcement, teams regain confidence quickly.

High performing IDTs share something simple and powerful. They know how they make decisions. They understand the method, the roles, the thresholds, the documentation expectations, and the responsibility to revisit the framework regularly. When this becomes routine, anxiety drops and confidence grows. Consistency improves. Conflict decreases. Participants experience fairness. Financial stewardship strengthens.

When organizations commit to building this foundation, improvement is often visible within weeks, not months.

Final Thought

Hiring talented professionals is critical. But talent without a common operating model creates variation. The earlier a program installs its decision-making foundation, the more stable the organization becomes. The IDT does not just happen. It is built deliberately.