Play by Play

Perspectives from leaders in the field of complex care.


When individuals participate in both Medicare and Medicaid, it would be ideal for them to be enrolled in one plan that integrates both programs and coordinates the benefits. And in some cases, this is already happening. But too often, these individuals—who are already highly vulnerable—are enrolled in entirely different, uncoordinated plans for each program. This further complicates an already fragmented delivery system for this high-needs group.
The Keystone ACO is a partnership between Geisinger, Evangelical Community Hospital, Wayne Memorial Hospital, and the Wright Center for Graduate Medical Education. It serves 73,000 Medicare beneficiaries in the Medicare Shared Savings Program (MSSP). Keystone ACO’s beneficiaries include residents of 41 primarily rural Pennsylvania counties as well as parts of New York, New Jersey and Maryland.
One of the most pervasive challenges in our health care system is allowing people to optimize their independence and continue living at home as they age and develop more complex health and social needs. These individuals often need long-term services and supports (LTSS), and their number is increasing. It’s estimated that the population of Americans in need of LTSS will rise to 27 million by 2050.
Caring for the complex chronically ill — a population that makes up about 5 percent of patients and nearly 50 percent of health care spending — is remarkably challenging. It’s also essential, as the United States transitions to a health care system that is driven by value.

By Rebecca Clark, Institute for Healthcare Improvement

If you’ve seen how quickly a relatively mobile older adult can turn into a frail and bedbound patient — not because of a primary illness, but because of a lack of movement — then you can appreciate how dramatically different care is at Saint Joseph Mercy Health System in southeast Michigan, and Anne Arundel Medical Center in Annapolis, Maryland.

The program, known as Community Aging in Place — Advancing Better Living for Elders (CAPABLE), is a client-directed home-based intervention to increase mobility, functionality, and capacity to “age in place” for older adults.
Many studies have highlighted the importance of effective interprofessional care teams to improve health outcomes for people with complex needs. But many programs do not take advantage of the special training of social workers to meet these needs on their primary health care teams.