Guest Columns

Coordinated care: Recommendations to improve quality

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Bruce Chernof, M.D.
Bruce Chernof, M.D.

Despite all of us having heard at least one story of good medicine gone wrong, coordinating care among skilled nursing facilities and home- and community-based services (HCBS) can be a win-win situation.

Cal MediConnect, California's demonstration program to better integrate care delivery and financing across Medicare and Medicaid for those dually eligible can both improve care for beneficiaries and support program/facility administrators.

A summary of 10 Recommendations to Strengthen Integrated Care includes lessons that can be applied on a larger scale. These include:

  • Clarify guidance on “person-centered care” and provide a common framework for all states.
  • Develop pathways to care coordination and use assessments to identify at-risk individuals.
  • Incentivize transitions to community-based services.
  • Increase affordable housing for this population.
  • Drive quality with value-based payments.
  • Continue offering technical assistance to states for integrated care system development. 

While these recommendations are generally for the consideration of the Centers for Medicare & Medicaid Services, they can be applied by delivery system leaders such as long-term care facilities to improve care delivery and quality. 

Care delivery

People with complex care needs can particularly benefit from a person-centered approach to care. Dual eligibles are more likely to experience significant functional and cognitive impairments, and have greater need for care coordination. Offering a person-centered care framework is a cornerstone of Cal MediConnect, yet there is no universal understanding of what this type of care means. For SNF and other long-term care providers, this would increase their knowledge of what to expect from health plans, as well as the expectations of their own care management practices.

Many duals demonstration health plans do not have consistent methods for determining individuals who would benefit from care coordination. Yet we know that individuals with long nursing facility stays face increasing challenges around their ability to transition back home or to a supportive housing environment. This is especially true for people who stand to lose their subsidized housing. Having a care coordinator can make all the difference in the world, connecting at-risk individuals to the community-based services they will need upon discharge. These community transitions should be incentivized by CMS as a best practice, ensuring that individuals get the right care, in the right setting, and at the right time. Successful transitions also reduce hospital and SNF readmissions, creating potential efficiencies in our healthcare and long-term care systems.

What can be done now? SNFs can begin implementing person-centered care approaches into their care plans with an eye toward transitions of care. This means capturing the needs, values, and care preferences of residents and family members early on and building that into the total care planning process. SNFs also have the opportunity to build and/or strengthen relationships with health plans and advocate for care coordination services to serve their residents. 


High-performing systems of care incorporate person-centered quality standards across the continuum. SNFs have an opportunity to partner with health plans within integrated systems of care to improve the overall experience and provide higher quality of care. Implementing person-centered quality measures that account for an individual's goals and values can provide results-driven metrics for care providers and administrators.

While Cal MediConnect introduced incentives that resulted in increased quality oversight of providers, health plans and providers experienced an increase in required reporting resulting in frustration among all involved. To make the process less burdensome, CMS should gather input from key stakeholders on which measures are critical and have the most impact. Second, CMS should align administrative processes, such as grievance procedures, across all payers to alleviate confusion. Further, CMS should continue providing technical support and expertise to states as they implement integrated approaches to care and share best practices to build a national high-quality healthcare system for older adults.

What can be done now? Realizing the potential for high-quality, person-centered care exists when all delivery system providers, including health plans and SNFs, work together to ensure care plans are timely, consistent, and well implemented. SNFs can start by requesting residents' care plans from the health plans to confirm alignment, and they can work with the health plans' care managers to make sure that individuals' and family members' needs and values are addressed, especially during transitions. SNFs can also work with health plans they have contracts with to streamline data collection and reporting processes.

Providing a highly integrated and coordinated system of care for dual eligibles isn't easy, but there are steps we can take now to support our long-term care residents and older adults living in the community.  For care delivery and quality to improve nationwide, these recommendations need to be implemented at the federal level to have a lasting impact. A fully coordinated system of care is possible, and it's up to all of us to be engaged. 

Bruce Chernof, M.D., is the president and CEO of The SCAN Foundation. 


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Guest columns are written by long-term care industry experts, ranging from academics and thought leaders to administrators and CEOs.