Coordination of Care

Care coordination is a critical element of both long term care and chronic care delivery systems. Persons with long term care needs often require services and supports financed by differing programs and provided by multiple entities.  To overcome this fragmentation, states have established single entry points for accessing services, creating an umbrella under which multiple long term services and supports can be coordinated. These case management programs have streamlined access to Medicaid long term care services. However, they typically do not have authority to coordinate the primary and chronic health services needed by persons who have limitations in conducting activities of daily living. For dual eligibles these services are financed by the Medicare programs.
Likewise, persons with multiple chronic illnesses often need help coordinating their health care services, which are frequently provided by multiple specialists who separately treat each chronic condition.  People having both complex health needs and limitations in daily living activities have even more challenges in coordinating needed services across chronic and long term care systems.
NASHP’s work in this area has supported states in defining the need for better care coordination, identifying strategies for improving care, and making the case for policy changes that would enable states to better integrate the delivery of primary, chronic and long term care.