Coordination of Care for Persons with Disabilities Enrolled in Medicaid Managed Care: A Conceptual Framework to Guide the Development of Measures. G. Care Coordination And Structural Integration Of Services


The classic "staff model" Health Maintenance Organization (HMO) can be viewed as an attempt to provide structural support for the coordination of care for enrolled members. Indeed, managed care leaders from such HMOs believe that they are uniquely well positioned to provide coordinated and more effective care to people with chronic conditions and disabilities. The idea here is to pull together, in a single organizational structure, all the professionals and services needed to provide health care to a defined population of enrollees. This is sometimes referred to, in the health care management literature, as "vertical integration"(Devers 1994).

In fact, using structural means to achieve coordination has a long history. This author was involved, during the War on Poverty, with efforts to create "multi-purpose neighborhood centers" that would integrate in one physical location, and under the governance of a single community-based board, a full range of human services needed to help people move out of poverty. The Model Cities program included similar efforts. Today, building on the expanded capabilities of information and communication technologies, attempts have focussed on a more "virtual" structural integration, related to the concept of "one-stop shopping." In this approach, a client can access a full range of services no matter where they enter the "virtually integrated" system, because of carefully designed flows of information regarding eligibility, appointment schedules, etc.

In today's health care world, most HMOs are moving away from tightly organized staff models, making it more difficult to use structural features to support care coordination. At the same time, however, provider systems have been and are being developed in which a continuum of services are structurally integrated (including through the use of information systems), even though the providers may contract with multiple MCOs. We cannot depend upon the existence of structurally integrated systems. On the other hand, there may be elements of such systems that are of particular importance in supporting care coordination. These are discussed in Section VII below.

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