have often been developed around identifiable episodes, such as congestive heart failure or knee replacements. Examples of Policy Levers: • Expanding effective demonstration programs nationally that employ bundled payments, such as the Acute Care Episode (ACE) bundled payment demonstration. • Phasing in alternatives to fee for service payment, such as bundled payments, within Medicare and Medicaid. • Exploring new opportunities for demonstration programs to incentivize adoption of evidence-based care pathways. Active Organizations: American Association of Kidney Patients, National Academy of Social Insurance, America’s Health Insurance Plans Focus Area: Disease Management Programs Disease management programs focus on coordinating treatments for one or multiple chronic conditions, such as cancer, COPD, and heart failure in which patient self-care is central for success. Models such as integrated disease management (IDM) establish an integrated care program of selfmanagement, exercise, and nutrition in which multiple healthcare providers collaborate to provide care. These programs require both interventions with patients as well as organizational changes to be effective. When applied to COPD, IDM interventions were proven to significantly improve quality of life and reduce respiratory-related hospital admission and stay. Disease management programs are typically implemented through managed health plans or government payers. Policy levers to create or incentivize effective disease management programs have the potential to improve patient health outcomes and decrease healthcare spending. Addressing the Health Needs of an Aging America | 22 Examples of Policy Levers: • Providing coverage for cancer care planning and coordination under Medicare. • Development and implementation of national standards for treatment summary and care plan templates. • Coordinating and integrating health and long-term services and supports for individuals living with Alzheimer’s Disease. • Incentivizing the development of chronic-care system interventions such as Money Follows the Person that promote patient-centered care. Active Organizations: American Society of Clinical Oncology, Alzheimer’s Foundation of America, American Association for Geriatric Psychiatry Focus Area: Primary Care Coordination Improving access to comprehensive primary care has been identified as a model for improving quality and safety outcomes in the aging population. The research literature suggests that the targeted use of medical homes for several chronic conditions, including congestive heart failure, major depression, and diabetes mellitus can be effective for improving health outcomes for the elderly. Collaborative care management, which is a nurse-delivered model that coordinates physical and mental healthcare for depression and other multi-morbid conditions, has been proven as another cost-effective approach to coordinate care. Examples of Policy Levers: • Expanding access to patient-centered medical homes in public and private health coverage. • Aligning requirements for Medicare Shared Savings Program ACOs with current requirements for medical homes or collaborative care models. Active Organizations: America’s Health Insurance Plans, Association of Asian Pacific Community Health Organizations Addressing the Health Needs of an Aging America | 23 Focus Area: Care Transitions and Patient Navigation Moving patients from one healthcare setting to another or back into the community is a high risk situation with great potential for poor quality and outcomes. Care transition programs, including discharge planning, as well as patient navigation programs are designed to help at-risk patients transfer between levels and settings of care and navigate the complex healthcare system. Randomized controlled trials of transition-oriented interventions have been shown to reduce readmissions for complex chronic conditions. Particularly successful interventions involve assigning nurses as clinical managers and providing in-person home visits to discharged patients. Among others, transitional care programs designed for individuals with heart failure improve quality of