The decision-honoring layer that keeps participants home.
You already hold the capitation and the clinical expertise. What's structurally unowned is the layer that carries a participant's own values to the bedside when she can no longer speak — and the cooperative workforce that delivers the presence that keeps her out of the hospital. That's what we'd bring.
PACE rewards exactly what a decision-honoring model produces.
PACE pools Medicare and Medicaid into one capitation and lets the interdisciplinary team fund whatever it deems necessary to keep a participant home — no fee-for-service code required. Home-retention and quality are the scoring axes, and they're under fresh federal attention (MACPAC's 2026 work to strengthen PACE oversight and quality measurement). A model that honors documented values and surrounds the family with presence performs precisely on those axes.
42 CFR Part 460 · MACPAC, Understanding PACE (2025) · NACHC PACE reimbursement guidance · NPA.
Three people stand at the bedside. None can hold the decision cleanly.
The advance directive is the easy half. The hard half is interpretation in a circumstance the document never anticipated — the woman who wrote "no long ICU stay" after watching a friend die on a ventilator, then breaks a hip, where a brief admission would actually serve her goal of staying comfortable and independent. Read literally, the document fails her. Read through her values, by someone who knew them, it doesn't.
Has the authority and the facts — but never knew the person.
Knew the person — but is grief-flooded, internally split, and carries the lasting weight of whatever they decide.
Is the only one who knows what she wanted — and the one who can no longer say it.
You see this scene constantly. The interpretive seat between those three is the one nobody is resourced to hold.
A neutral values fiduciary, backed by a living record.
A trained co-op.care doula — non-clinical, IDT-adjacent — fills the fourth position: not a decision-maker, but the one who can say, with documented grounding, here is what she told us mattered, here is the good day she described, here is why "comfort" and "everything" each meant something specific to her. She advocates; the legal proxy decides; your IDT authorizes. She doesn't decide — she makes the participant present in her own decision, and de-escalates the 3 a.m. crisis before it becomes an unwanted admission.
And she is not a freelancer. co-op.care employs these caregivers as W-2 worker-owners — putting a trained, fast-growing, largely unemployable presence workforce to dignified, accountable work, governed by your IDT and the firewall below.
CareGoals carries the values across the whole arc.
CareGoals is live today: a ~20-minute guided conversation (not a form) that produces a readable values summary and a designated proxy, framed around "if you couldn't speak for yourself, what would you want?" It builds the values summary and proxy designation; a clinician or attorney formalizes the legal instruments — that line stays clean. The partnership turns it from a one-time intake into the living record the doula reads from and writes to:
Capture
Values, proxy, preferences, family circle — at enrollment, before any crisis.
Carry
Reviewed and updated as the participant declines and circumstances change — the dynamic process good ACP requires and a static directive never gets.
Activate
At the decision point, the documented values come into the IDT and the bedside — interpreted in the real circumstance, not recited from a stale form.
Continue
After death, the same record anchors bereavement continuity for the family that already trusts it.
The firewall is the whole point.
A trusted third party near end-of-life decisions, inside any organization that benefits financially from less aggressive care, is a conflict that must be engineered out — not managed quietly. We want this designed with your ethics committee, and externally reviewable, before a single participant is touched.
How we make the values fiduciary defensible.
- check_circle External review through your ethics committee. TRU is a hospice; you already have the body that makes anti-steering credible to a regulator and a family. Oversight lives there, not inside co-op.care.
- check_circle Compensation provably disconnected from utilization. The doula's pay and evaluation never touch cost or care-intensity outcomes. Full stop, and documented.
- check_circle She surfaces values — including when they point toward aggressive treatment. The standard is the participant's voice, not the cheaper path. Audited against decisions for any steering pattern.
- check_circle Bright line on role. Advocate, never decide. Non-clinical, always. The proxy decides; the IDT and Medical Director own all clinical judgment.
Impact and capitation point the same way.
Honoring a participant's documented "comfort over machines" prevents the avoidable ICU week, the futile ventilator, the nursing-home placement she never wanted — the low-value, unwanted care that, under your full capitation, is TRU PACE's own cost. The decision system isn't a charity line; it's the mechanism by which the participant's stated values and the program's economics align. That alignment is exactly why the firewall must be airtight — and why, done right, it's a quality differentiator no competitor has built.
The dying participant, at the top of her own decision — and the program rewarded for honoring it.
One small, instrumented pilot.
TRU PACE brings
The capitation, the interdisciplinary team, the clinical and Medical Director authority, and the ethics committee that governs the firewall.
co-op.care brings
The trained W-2 cooperative doula workforce, CareGoals as the living system of record, the decision-surrogacy model, and the firewall design.
Together
A differentiated, decision-honoring care layer — and the home-retention and quality data that PACE oversight increasingly rewards.
The pilot
- Structure: the doula + decision-surrogacy service as a discrete, IDT-authorized line within a sub-capitation arrangement — scoped so it's clean against PACE rules, AKS/Stark, and FMV.
- Cohort: a small group of participants with end-of-life planning needs, enrolled in CareGoals at the front.
- Metric: we instrument one defensible signal — avoided end-of-life ICU days / 30-day pre-death hospitalization — so the model proves itself in your own numbers.
- Term: a defined pilot window, reviewed with your ethics committee throughout.
Honest framing: co-op.care and TRU PACE / TRU Community Care are independent organizations; this is a proposal for discussion, not an agreement. co-op.care is an early-stage Colorado Limited Cooperative Association — CareGoals is live; the PACE decision-surrogacy service described here would be built with you. PACE structure per 42 CFR Part 460 and CMS/MACPAC materials. Nothing here is binding; any arrangement would be papered in definitive agreements and reviewed by each party's counsel and ethics committee.