Transforming Care for Medicare Beneficiaries with Chronic Conditions and Long-Term Care Needs: Coordinating Care Across All Services


This policy brief is the first of two publications from Georgetown University on transforming models of care. The paper affirms that in order to improve care delivery and manage costs, innovations for Medicare beneficiaries who have both chronic conditions and functional impairments should be a top priority.

Date Updated: 10/12/2011

I. Introduction

People with chronic conditions are at center stage in efforts to transform health care delivery from encouraging more—and more-costly—services to promoting prevention, primary care, and care coordination. Fragmentation and lack of coordination in health care services are increasingly regarded as not only a source of frustration for patients, but also as both impediments to quality care and drivers of health care costs. The Affordable Care Act accordingly charges Medicare with payment and delivery reforms to improve care and slow cost growth not only for its beneficiaries, but to jumpstart and influence system-wide change…

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In this paper, the National Committee for Quality Assurance (NCQA) discusses prior integration efforts; introduces a model for integrated entities and a framework for assessing and promoting quality of integrated care; and explores the challenges to implementing and achieving the goals of person-centered, integrated care for Medicare-Medicaid beneficiaries. They use the word “framework” to describe the key concepts underlying the structure and process measures; it can also be expanded to include the content of performance measures as companions to the structure and process measures.

People tend to be very satisfied with their long-term care providers when they start their care, but satisfaction decreases over time.

The SCAN Foundation aims to identify models of care that bridge medical care and supportive service systems in an effort to meet people’s needs, values, and preferences. Care coordination is a central component of this vision, which ultimately leads to more person-centered care. This brief outlines The SCAN Foundation’s vision for care coordination in a person-centered, organized system.