Integrating Community-Based Services into Care for Seriously Ill Populations

Patient-centered clinical medical care is critical to improving the lives of those with serious illnesses. That care, however, has been traditionally delivered in a silo and should be accompanied by community-based supports and services that address the social conditions of patients and their families. Community-based organizations (CBOs) offer aid like spiritual care, housing support, transportation, and healthy meals that ensure that medical care is most effective. However, CBOs often lack infrastructure support, including sustainable financing models, IT support, and workforce to support this population in their community.

The Commonwealth Fund estimates that 12 million individuals aged 18 and older living in the community have high healthcare needs, defined as “people who have three or more chronic diseases and a functional limitation in their ability to care for themselves (such as bathing or dressing) or perform routine daily tasks”; this population includes a large portion of individuals with serious illness. An interdisciplinary, team-based approach to care for these patients helps to ensure that their complex needs are better addressed. Access to support and services from CBOs can help empower those with serious illnesses to stay in their communities and reduce demand for emergency department visits and hospital care while increasing access to more affordable care and satisfaction with care for them and their families. CBOs represent care in the community settings that are both responsive and reflective of the people they serve. People who may not be able to access care due to distance or economic challenges can have those needs filled by CBOs where culturally knowledgeable and responsive providers can better assist patients with getting the care they desire. Without sustainable funding for CBOs, inequities in care can persist.

C-TAC approach to Address the Problem:

-Reform finance structures to enable CBOs to be funded through Medicare reforms and include a palliative care services benefit.

-Innovative Medicaid funding. States can use Medicaid waivers, state plan amendments, and other avenues to align social support with medical services such as palliative care.

- Support nonmedical care like meals, transportation, housing, home health visits, and spiritual care to improve health care outcomes. Groups like Area Agencies on Aging (AAA) and other nonprofit organizations provide services that bridge the gap between hospital and community.

- Reduce family caregiver burden through the integration of CBOs. CBOs that can provide home health services, transportation, meals, and more reduce the amount of time family caregivers spend on those activities. Caregivers should be able to access CBOs that will better assist them without creating more financial hardship.  

- Increase interoperability and data sharing between CBOs and health care providers. To be truly integrated into health care, CBOs need technology support. Secure data sharing ensures CBOs have up-to-date patient information and have the technology supports to maintain records and communicate more easily with health care providers.

- Encourage value-based payment structures that create incentives for using CBOs to help deliver more holistic outcomes for those living with serious illnesses.

Calls to Action

  • Fund the nation’s Area Agencies on Aging (AAAs), others in the Aging Network, and other community-based organizations (CBOs), and full implementation of the Older Americans Act provisions directing the Administration on Aging to disseminate and collect feedback on its Principles for Person-directed Services and Supports during Serious Illness.
  • Expand Medicare alternative payment models to include non-medical social supports and services, including palliative care services
  • Increase funding for the Racial and Ethnic Approaches to Community Health (REACH), which is the only CDC program that funds communities working to reduce racial and ethnic health disparities, and for State Health Insurance Programs (SHIP).