Mona Siddiqui, MD, MPH, MSE, Senior Vice President, Clinical Strategy and Quality, Enterprise Clinical Management at Humana reflects on the importance of the integration of clinical and community-based services.

Core Principles for Care Models

All persons living with serious illness should have access to equitable care reflecting these core principles, regardless of who pays for that care. Currently, they often receive services contrary to their individual care preferences while needed community services remain underfunded and utilization of palliative care and hospice is low. As a result, too many of these persons and their families, and especially people of color and historically marginalized groups, have high unmet needs and poor quality of life.



  1. Care is person- and family-centered, improving quality of life.
  2. Care is inclusive – reducing inequities and disparities, and removing barriers to access and to quality care.



  1. Each person’s physical, social, psychological, and spiritual needs are assessed on an ongoing and standardized basis.
  2. A care plan is developed, using shared decision making, based on those needs and the person’s individual goals and preferences.
  3. Care is provided by a qualified core interdisciplinary team, with additional team members as needed.
  4. Care is accessible 24/7 (using technology as appropriate) and available throughout the continuum of a serious illness (including in the home when appropriate).
  5. Care is comprehensive, coordinated, with seamless transitions, and with integration of clinical and community-based services and supports for the person and family caregiver(s).



  1. Payment is value-based, available to qualified organizations of any size, and includes risk adjustment, upfront investment, accountability, standardized metrics, and quality improvement, and covers both clinical and social services.

At the core of our 2030 Moonshot is a future where everyone with a serious illness, especially those most in need, has access to high quality care from diagnosis through to the end of life.

To get there we need to ensure that — no matter their illness, no matter their age, no matter who’s paying for care, no matter the care model — the patient and family have access to care based on what matters most to them.

That’s why we’ve developed Core Principles for Care Models for Those with Serious Illness   to provide clear guideposts that can be used to evaluate payment and care models, and align with the evidence-based 4th edition of the National Consensus Project Clinical Practice Guidelines and the latest research. Click here to learn how our new principles align with CMMI’s new strategy to transform health systems.

How you can use them:

  • As a checklist for evaluation of current and planned programs
  • As a source for ideas for improving current and future models.

How you can help:

  • Give us your feedback on the Principles – do they capture how you would evaluate high quality care?
  • Tell us about which Principles you’re currently working on, where you’ve had successful breakthroughs, and where you’re running into policy barriers or opportunities to expand the work.


For more information or to provide comments on these principles, please contact us at