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  1. Master, Robert MD
  2. Simon, Lois MPH
  3. Goldfield, Norbert MD


Abstract: While medical care is becoming more effective, our health care system is becoming increasingly fragmented from both a care and a financing perspective. This article summarizes our experience with integrating the delivery of care for catastrophically ill and frail elderly. We argue that true integration can only be done within a framework of a financing mechanism that gives all providers the financial incentive to deliver integrated care. Under such a financial arrangement, nurse practitioners and social workers provide much of the care within the home environment. This results in a higher quality care delivery system within a limited budget.


OVER THE PAST 50 years, physicians and other health care professionals have worked together to try and create structures that provide a higher quality of care at a reasonable cost to individuals with a significant chronic illness (SCI), such as HIV or paraplegia. Over the past decade, several organizations have attempted to address the increasingly complex challenges to the delivery of cost-effective care for individuals with SCIs. These challenges include the following:


* increased medical advances that enable individuals with SCIs to lead productive lives, provided they are able to access appropriate services for their conditions


* the fragmented nature of the delivery system for many of these medical advances, leading to a desire to better coordinate these services on the part of both individuals with SCIs


* the disorganized and disparate benefit structure for many of these services, some of which are paid out of health care insurance while others may be paid for from other social insurance programs (Other needed services are often not reimbursed at all under any form of insurance.)


* increased engagement on the part of individuals with SCIs to demand their right to access necessary care for their complicated medical conditions



This article briefly provides a history of the efforts to date of Commonwealth Care Alliance (CCA), and in particular its forerunner, Community Medical Alliance (CMA), and contextualizes the importance of consumer involvement in health care organizations.