Coordination and Integration for Individuals with Chronic Illness


People needing long-term services and supports (LTSS) often require both health-related and personal care services. This varies by condition and by the amount of assistance they receive from family and friends. They may, for example, need nursing care but also the preparation of meals, help paying bills, and transportation. This is especially true among people with chronic illnesses.

According to 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. In 2012 about 86 percent of people age 65 and older had at least one chronic health condition, and 61 percent had two or more. For many of these people, the conditions 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 the policy discussion in 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. Integrated options for people eligible for both Medicare and Medicaid include the Program of All-Inclusive Care for the Elderly (PACE) and Medicare dual special-needs plans. These are Medicare Advantage plans for people who are dually eligible for Medicaid and Medicare (see Chapter 7, Health, for a discussion of dual eligibility). These and other integrated options have pioneered promising approaches but, with the exception of PACE, are still relatively new.

The Affordable Care Act created the Center for Medicare & Medicaid Innovation 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.

Coordination and Integration for Individuals with Chronic Illness: Policy

Integrating health care and long-term services and supports (LTSS)

In this policy: FederalState

Governments should develop comprehensive, coordinated approaches to financing and delivering care to chronically ill people, including physical and mental health care and LTSS, such as chronic-care self-management.

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.

Financing care for the chronically ill

In this policy: FederalState

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 and/or mental disabilities and those eligible for Medicare or Medicaid (for Medicare policy, see Chapter 7, Health).

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