Background
Many chronic illnesses and other health conditions—such as heart disease, cancer, multiple sclerosis, arthritis, diabetes, and emphysema—can result in functional limitations. Some acute conditions, such as a stroke, can also cause multiple functional limitations.
Long-term services and supports (LTSS) needs vary by condition. Individuals may need both nursing care and assistance with ADLs and IADLsManaging medications, preparing meals, managing finances, using the telephone, housekeeping, doing laundry, shopping, using transportation. . Health insurance covers primary care and treatment of acute medical conditions. However, it does not cover LTSS, such as personal care, adult day care, homemaker servicesThese services include meal preparation, cleaning, laundry, shopping, and other household chores; they may include informal monitoring of clients’ health and functional status., or transportation. Thus, many frail older adults lack the services and supports they need to function independently at home.
For people with chronic conditions, timely preventive and primary health care can reduce the development of functional limitations. Timely acute care can do the same, for example, immediate treatment for people who have early symptoms of a stroke. Comprehensive rehabilitation services can lessen the severity of functional limitations.
For people with both health and long-term services and supports (LTSS) needs, navigating multiple systems of care can be difficult. Lack of coordination among health and LTSS providers can result in suboptimal care.
An increasing number of programs and health plans are starting to recognize the benefit of offering a full range of medical and supportive services, as well as devising better ways to coordinate these services (see also Chronic-Care Coordination and Accountable Care Organizations for approaches to improving care for people with multiple chronic illnesses; and Managed Care for Dually Eligible Medicaid Beneficiaries).
The Center for Medicare & Medicaid Innovation (CMS) supports efforts to integrate medical and supportive services. CMS is testing new payment and service delivery models that have the dual goal of reducing Medicare and Medicaid expenditures while preserving or enhancing quality of care. CMS is also authorized to test new financing models that enhance care integration, particularly for individuals eligible for both Medicare and Medicaid (dual-eligibles). These innovations may address some of the issues facing people who receive services through both programs and thus have to navigate two separate and complex delivery and financing systems.
In an effort to provide seamless service delivery, some service models integrate funding sources so that individuals do not have to navigate separate systems to obtain both health care and LTSS. Integrated financing options for people eligible for both Medicare and Medicaid (known as the dual-eligibles or duals“Duals” are individuals who are eligible for both the Medicare and the Medicaid programs, also called dual eligibles.) include the Program of All-Inclusive Care for the Elderly, also known as PACE, and dual special-needs plans available through Medicare AdvantageMedicare Advantage (MA) health plans are offered by private Medicare approved companies as an alternative to Original Medicare. Medicare pays these companies a fixed amount per enrollee per month to provide benefits for Parts A, B, and (usually) D. plans.
COORDINATION OF HEALTH AND LONG-TERM SERVICES AND SUPPORTS: Policy
COORDINATION OF HEALTH AND LONG-TERM SERVICES AND SUPPORTS: Policy
Coordination and integrated financing of services
Federal and state governments should develop comprehensive, coordinated approaches to financing and delivering care to individuals whose needs are currently met through multiple service systems.
Federal and state governments should actively incorporate the needs of family caregivers People who provide long-term services and supports to family members, relatives, friends, and neighbors. Some family caregivers are unpaid; others are paid through government programs, private funds, or long-term care insurance policies. in developing new financing and care delivery models that focus on coordination and quality improvement.
Evaluations are needed to identify specific financing mechanisms and delivery systems to serve subgroups of chronically ill individuals who need both ongoing medical care and long-term services and supports, such as people with physical or mental impairments, or both, as well as those eligible for Medicare and Medicaid (see also Health Care Coverage: Medicare).