Improving the Health of Older Adults Using Integrated Networks for Medical Care and Social Services

Friday, July 10, 2015

by Nora OBrien-Suric, Senior Program Officer, The John A. Hartford Foundation

In June 2014 The John A. Hartford Foundation Trustees approved a $2,068,500, three-year grant to develop prototype networks that link community-based, social service agencies to the health care sector, with the goal of establishing an integrated health care and social services delivery system. The project is developing exportable tools and lessons that are shared with other agency networks supported by the Administration for Community Living (formerly the Administration on Aging) with technical assistance and training to enable the social service providers to collaborate and contract with each other, as well as with health care providers and health insurance plans.  
Social service agencies are expert at addressing the social determinants of health and ensuring that people with complex care needs, such as older people who have difficulty with daily tasks and younger people with disabilities, will receive the critical services necessary to help them remain in the community.  Services provided include home delivered meals, shopping, cooking, bathing, bill paying and/or emotional support, as well as support for their caregivers. In-home assessments determine exactly what is needed for each individual and their family.  In order to successfully partner with the health care sector, social service agencies need technical assistance in creating organizational culture change, conducting market analysis, developing service packages, pricing services, and negotiating contracts.  
Together, medical care and social services are better able to provide comprehensive care, while lowering health care costs, and improving health outcomes.  Already, the new partnerships have shown a 50% decrease in hospital readmissions.
As our population ages and more and more people are living longer with disabilities and multiple chronic conditions, the current network of aging and disabilities agencies will not be able to provide the services that will be needed with the current levels of resources. Because the current model of funding social services agencies cannot meet the nation’s needs, the Administration for Community Living (ACL) is supporting initiatives to fortify and sustain the aging and disability services network. The ACL (which includes the Administration on Aging) serves as the federal agency responsible for increasing access to community supports, while focusing attention and resources on the unique needs of older Americans and people with disabilities of all ages.
The agency has developed several initiatives for aging and disability services through the numerous opportunities that arose with implementation of the Affordable Care Act (ACA). Two sections of the ACA in particular are relevant when it comes to the integration of health and long-term services and supports:
  • Section 2602 of the ACA established the Medicare-Medicaid Coordination Office (MMCO), within the Centers for Medicare & Medicaid Services (CMS). Its goals are to “make sure Medicare-Medicaid enrollees [also known as dual eligibles] have full access to seamless, high quality health care and to make the system as cost-effective as possible. 
  • Section 3022 of the ACA established the Medicare Shared Savings Program, a three-year program enabling providers of services for Medicare beneficiaries to work together in accountable care organizations (ACOs). 
The John A. Hartford Foundation is committed to improving the health of older Americans and is working with the ACL in disseminating new partnership models.  This grant initiative highlights the financial advantage for health care systems by partnering with social service agencies in reducing health care costs while improving health outcomes.  With New York State one of the CMS Dual Demonstration states the time is right to promote these medical/social service partnerships. Contact us for more information.  
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