Blueprint for health plans: Integration of community-based organizations to provide social services and supports

The current health care system does not adequately meet the needs of older adults with complex medical and social needs, which are intimately related. Despite mounting evidence that supports the integration of the medical and social models of care, the transition to a more comprehensive delivery system has not been simple or intuitive for health plans or social service providers. The result is that care often remains uncoordinated and fragmented for older adults, specifically for those eligible for both Medicare and Medicaid (referred to as dual eligible). Following is an examination of the challenges and opportunities that health plans serving the dual eligible population face and a roadmap for how plans can develop networks that reflect both the social and medical needs of members. However, it is important to recognize that plans are only one part of the system that serves the dual eligible population, and coordination efforts by all the organizations and entities that serve this population is necessary to achieve a more person-centered system of care.