Caring for Complex Chronic Conditions

The Bipartisan Policy Center (BPC) on January 31, 2018, released their new policy roadmap “A Policy Roadmap for Individuals with Complex Care Needs” stressing the need to identify policy solutions on ways to finance and deliver quality care to this vulnerable population.

In 2010, 37 percent of Medicare beneficiaries had four or more chronic conditions and accounted for 90 percent of Medicare hospital readmissions and 74 percent of Medicare program spending. Challenges in delivering quality care for high need adults can be even greater for those who are considered low income or disabled and eligible for both Medicare and Medicaid.

Research shows that for some people with complex care needs, providing social services not traditionally covered by Medicare can reduce unnecessary hospitalizations and reduce emergency visits.

These services can include targeted care management, personal care services or other home or community-based assistive services, in-home meal delivery, home modifications, and transportation to doctor’s appointments. However, care models based on fee-for-service makes it difficult to provide this type of coordinated care.

“Ensuring better integration of non-Medicare covered health related supports and services into risk-based care models must be a top priority as we create new care delivery approaches,” according to Katherine Hayes, BPC’s Health Policy Director.

She also reports, “Providing these services to frail elderly adults or those with behavioral and social needs can improve care for patient and their caregivers, improve health outcomes, and in some cases even lower costs.”

BPC recommendations included in the Roadmap focuses on five policy areas:

  • Provide flexibility in Medicare Advantage to better integrate health and social services and supports for Medicare patients with the greatest needs and highest costs
  • Align programs serving dual-eligible Medicare and Medicaid beneficiaries to better coordinate care
  • Expand Medicaid options at home and in the community
  • Increase the availability and affordability for private long term care insurance to extend existing resources
  • Support family caregivers and ensure that long-term services and supports are made available through Medicare Advantage and Medigap.


The report also emphasizes that individuals with complex care needs should be able to receive person and family centered care, coordinated care that is not redundant in services and costs, strategies need to be used to eliminate barriers to coordinated care, family and caregiver support, plus financing strategies should be made available to assist with the delivery of long term services.

Go to for details on the Roadmap.

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