A Policy Roadmap for Individuals with Complex Care Needs

Providing quality care for individuals with complex care needs is one of the most pressing challenges facing the United States health care system. The Bipartisan Policy Center, with the support of The SCAN Foundation, The Robert Wood Johnson Foundation, The Peterson Center on Healthcare, and The Commonwealth Fund, has been working since 2013 to develop policy solutions focused on how to finance and deliver quality care to individuals with complex care needs.

This report draws from six previous reports to identify a roadmap of policy solutions that can begin to tackle the barriers to financing and delivering high-quality, person- and family-centered, coordinated health and social services and supports to individuals with complex care needs.

Individuals with complex care needs have been a population of focus as policymakers have worked to develop and implement program-wide health care delivery system reforms in Medicare. In 2010, 37 percent of Medicare beneficiaries had four or more chronic conditions. These beneficiaries accounted for 90 percent of Medicare hospital readmissions in 2010. Medicare beneficiaries with four or more chronic conditions also comprised 74 percent of Medicare program spending in 2010. Challenges for high-need people can be even greater for low-income older adults and individuals with disabilities who are eligible for both Medicare and Medicaid coverage. Many of these so-called “dual-eligible” beneficiaries have higher medical acuity, significant cognitive and functional impairments, and a greater need for care coordination and assistance with activities of daily living (ADLs).

Long-Term Care Planning: Tina and Ron’s Personal Story

Most Americans are not aware of the financial costs of long-term care and do not fully understand the time commitment and emotional cost of being a family caregiver. Yet every day, more than 40 million Americans take care of their loved ones so they can live independently at home.

“Tina and Ron are both 78 years old and retired. When Tina is diagnosed with dementia, she and Ron start to discuss how they will manage financially when Tina is no longer able to remain at home on her own.”

Tina and Ron’s story illustrates why discussing and planning for long-term care before a health crisis impacts the family are important for every household. Looking across BPC’s recommendations to improve the delivery of clinical services and long-term services and supports (LTSS) a range of health and social services provided to individuals who need help with daily tasks or ADLs?a number of consistent findings have emerged. The pathway to improving the quality of care and controlling the cost of serving individuals with complex care needs must address the following issues:

• A focus on person- and family-centered care, that places a priority on understanding the care goals of families and delivering the services that support them
• An emphasis on coordinating care to ensure that services work across programmatic silos and avoid unnecessary or duplicative care and costs
• Strategies to eliminate programmatic barriers to delivering coordinated care
• Creating a path from medical-driven models that provide care based on what is reimbursed to person-centered models that provide what people need and want
• Support for family caregivers
• Efforts to identify financing strategies, both public and private, to support the delivery of LTSS.