National Plan to Address Alzheimer's Disease: 2018 Update. Strategy 2.G: Advance Coordinated and Integrated Health and Long-Term Services and Supports for Individuals Living with Alzheimer's Disease and Related Dementias


Coordinating the care received by people with AD/ADRD in different settings by different providers can help reduce duplication and errors and improve outcomes. Despite a general consensus that care coordination is important, more research is needed to determine how best to provide such care in a high-quality and cost-efficient manner. The actions under this strategy will focus on learning from the existing evidence regarding care coordination and using this information to implement and evaluate care coordination models for people with AD/ADRD.

(UPDATED) Action 2.G.1: Implement and evaluate care coordination models

Multiple care coordination models and guidance on care coordination continue across CMS. CMS makes payment for care management and coordination services. Care coordination models can be a critical component of care in Medicare that can contribute to better health outcomes and higher beneficiary satisfaction. Starting in 2017, based on feedback from stakeholders, CMS has made separate payment in Medicare for complex care coordination models services, in addition to payment for non-complex care coordination models services that began in 2015. Beginning in 2017, CMS also has made several significant changes to requirements and payment for care coordination models services, including simplified and reduced billing and documentation rules. In 2018, CMS released an evaluation report on the diffusion and impact of care coordination models services.

CMS's Comprehensive Care Plus Model is an advanced primary care medical home model that rewards value and quality by offering an innovative payment structure to support delivery of comprehensive primary care. One of the payments under the model are prospective monthly care management fees, including a higher care management fee for patients with complex needs.

For more information, see:


Action 2.G.2: Assess the adequacy of health information technology standards to support the needs of persons with Alzheimer's disease and related dementias

ASPE continues work with HHS's Office of the National Coordinator for Health Information Technology and partners in exploring the feasibility and timing of activities to assess, identify, and fill gaps in accepted health information technology (HIT) standards for the representation of care plans to represent the health concerns, goals, interventions, and other information identified by individuals, caregivers and family members in caring for individuals receiving LTSS, including people with AD/ADRD.


(COMPLETED) Action 2.G.3: Compare outcomes for dual eligible beneficiaries in integrated care models

ASPE has completed a project to determine the feasibility of an analysis that compares selected health outcomes and quality measures for Medicare-Medicaid dual eligible beneficiaries participating in managed care models that align Medicare and Medicaid benefits, such as Medicare Advantage Dual Eligible Special Needs Plans (D-SNPs), Medicare Advantage Fully Integrated D-SNPs, and PACE, to outcomes for dually eligible beneficiaries who are not participating in these models. Dually eligible beneficiaries are almost three times more likely to have dementia as their Medicare-only counterparts, therefore programs that serve large numbers of dually eligible beneficiaries are likely to also serve people with dementia. This study aims to better understand whether dually eligible beneficiaries fare differently in different integration models across a number of categories including but not limited to, mortality, nursing home utilization, hospital readmissions, and chronic conditions (inclusive of AD/ADRD or Senile Dementia, as identified in CMS's Chronic Conditions Data Warehouse). Reports are forthcoming in September 2019.


(NEW) Action 2.G.4: Study the impacts of managed care on health outcomes and quality

ASPE has a project underway to evaluate the impact of Medicare and Medicaid alignment for individuals eligible for both Medicare and Medicaid on beneficiary outcomes and utilization of acute care services and LTSS. Nineteen percent of all Medicare-Medicaid dual eligible beneficiaries have AD/ADRD. This project will focus on one state (Tennessee) that has implemented Medicare and Medicaid financial alignment for duals through a combination of Medicare Advantage D-SNPs contracting and Medicaid managed long-term services and supports (MLTSS). This project is testing the hypothesis that the aligned delivery of Medicare and Medicaid-funded services to full-benefit duals is associated with improved health status and increased efficiency of health care utilization (decreased emergency department utilization, decreased nursing facility utilization, and increased use of HCBS) among full-benefit duals in Tennessee, by evaluating the impact that Tennessee's financial alignment strategy (pairing D-SNPs with MLTSS) has had on beneficiary outcomes and utilization. A report is forthcoming in June 2019.


(NEW) Action 2.G.5: Analyze pathways of eligibility for dually eligible beneficiaries

ASPE has a project underway to identify the frequency with which the various eligibility pathways to Medicare-Medicaid dual eligible status are utilized to understand the circumstances and characteristics of individuals surrounding their transition to dual status. Nearly one-quarter (23%) of Medicare-Medicaid dual eligible beneficiaries over the age of 65 have AD/ADRD. Individuals become dually eligible for the Medicare and Medicaid programs through multiple pathways. They can become eligible for one of the programs before the other, based on age, disability, or income; or they may simultaneously become eligible for both programs. However, current understanding of these pathways remains limited. Differences in the pathways to dual eligibility have implications for Medicare and Medicaid spending and service use patterns. Understanding these differences can inform policy efforts to support the Medicare-Medicaid dual eligible population and individuals at risk for becoming dually eligible. A report is forthcoming in December 2018.


(COMPLETED) Action 2.G.6: Analyze maintenance and loss of dual eligibility status

ASPE completed a project to document the frequency of Medicaid coverage loss among newly eligible full-benefit Medicare-Medicaid dual eligible beneficiaries and identify potential causes for coverage loss. Nineteen percent of all dual eligible beneficiaries have AD/ADRD. Generally, full-benefit dual eligible beneficiaries are expected to have relatively stable Medicaid enrollment due to their low income and high health care and LTSS needs, especially among older people and people with disabilities, whose income and assets are expected to be stable. Since dual eligible beneficiaries represent a vulnerable population, gaps in insurance coverage can compromise access to care and result in increased costs and decreased quality of care, further increasing an individual's risk for adverse health outcomes. A prior ASPE study found that a substantial proportion, approximately 30%, of new, full-benefit dual eligible beneficiaries identified during 2007-2010 lost full-benefit coverage for at least 1 month in the 12 months following their transition to full-benefit dual status. The study identifies potential causes for the loss of Medicaid coverage among full-benefit dual eligible beneficiaries to better understand the relationship between states' Medicaid eligibility and enrollment policies and reasons for loss of Medicaid coverage. A report is forthcoming in December 2018.


(NEW) Action 2.G.7: Understand issues specific to the "triple-user" population

ASPE has a project underway to better understand the demographics, service utilization patterns, health status and policy challenges facing the population that is simultaneously eligible for Medicare, Medicaid, and Veterans Health Administration (VHA) benefits. Some research estimates that as many as half of all current VHA enrollees are dually enrolled in Medicare. Additionally, nearly one in ten veterans has Medicaid as a source of health insurance coverage, some in combination with VHA and some with Medicaid as their sole source of coverage. Among veterans with Medicaid coverage 41% have Medicaid and VA, and 9% have Medicaid and Medicare. Veterans are significantly more likely than non-veterans to experience traumatic brain injury, a condition linked to later development of AD/ADRD. This project will explore the demographics and service use patterns of veterans who use multiple systems of care, with a special focus on triple-users, to better understand how these veterans compare to other populations with multiple system use (such as Medicare-Medicaid dual eligible beneficiaries), and inform the development of an analysis plan that will lay out a Road Map for future quantitative study of service utilization and outcomes in triple eligible veterans. A report is forthcoming in December 2018.