Ensuring Coordination of Services for Individuals with both Health and Long-Term Services and Supports Needs

Background

Many individuals with long-term services and supports (LTSS) needs have chronic illnesses and other health conditions, such as heart disease, cancer, and multiple sclerosis. LTSS and health care needs can impact each other. Lack of preventive and primary health services can lead to acute events and a worsening of functional limitations. Thus, it is essential to ensure that people with both health and LTSS needs receive all necessary care and that this care is coordinated whenever feasible.

Health-related and personal care service needs vary by condition and by the amount of assistance they receive from family and friends. Individuals may, for example, need nursing care but also assistance with the preparation of meals, paying bills, and transportation. This is especially true among people with chronic illnesses.

According to the Centers for Disease Control and Prevention data, chronic conditions include arthritis, hypertension, heart disease, diabetes, stroke, cancer, hepatitis, weak or failing kidneys, current asthma, and COPD. Chronic conditions can result in functional limitations, requiring some LTSS. While medical insurance will cover services to address acute medical conditions, it does not typically cover personal care, adult day care, homemaker services, or transportation. Thus, many frail older adults lack the services and supports they need to function independently at home.

An increasing number of programs and 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 Chapter 7, Health - Chronic Care Coordination, Medical Homes and Accountable Care Organizations for approaches to improving care for people with multiple chronic illnesses). With the consent of the person receiving services, efforts to incorporate family members and caregivers in the coordination and integration of service delivery can improve outcomes (see also Chapter 7, Health – Managed Care for Dually Eligible Medicaid Beneficiaries).

The Affordable Care Act created the Center for Medicare & Medicaid Innovation (CMMI) to support further efforts to integrate medical and supportive services. The center 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. The center is also authorized to test new financing models that enhance care integration, particularly for individuals eligible for Medicare and Medicaid (dual-eligibles). These innovations may address some of the issues that confront people who receive services through both Medicare and Medicaid and thus have to navigate two separate and complex delivery and financing systems.

Some service models integrate funding sources in an effort to provide a seamless service delivery so that individuals do not have to navigate separate systems to acquire and coordinate health and LTSS. Integrated financing options for people eligible for both Medicare and Medicaid (known as dually eligible or duals) include the Program of All-Inclusive Care for the Elderly (PACE) and dual special-needs plans available through Medicare Advantage.

ENSURING COORDINATION OF SERVICES FOR INDIVIDUALS WITH BOTH HEALTH AND LONG-TERM SERVICES AND SUPPORTS NEEDS: Policy

Ensuring the coordination and integrated financing of health care and long-term services and supports

In this policy: FederalState

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.

Policymakers should emphasize preventing disabilities and functional limitations among individuals with a chronic illness and minimizing disability or functional loss if one occurs.

Federal and state governments should proactively incorporate the needs of family caregivers in developing new financing and care delivery models that focus on coordination and quality improvement.

Good 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 LTSS; for example, people with physical or mental disabilities, or both, and those eligible for Medicare or Medicaid (see also Chapter 7, Health – Health Care Coverage: Medicare).