An interdisciplinary team (IDT) brings together knowledge from different health care disciplines to help people receive the care they need. For example, in the disability-competent care (DCC) model, the core members of the IDT include a primary care provider (PCP),

Health plans that contract to provide comprehensive care to beneficiaries dually eligible for Medicare and Medicaid may find it beneficial to collaborate with community partners that provide services beyond direct medical care such as housing, transportation for non-medical needs, and

Substance use is a primary concern for dually eligible individuals. Substance use conditions refer to the misuse of alcohol, illegal drugs, or prescribed medications in ways that produce harm to an individual and their environment.1 At least 60% of dually

Health plans and providers seeking to provide culturally competent care and services to individuals from diverse backgrounds have incorporated community health workers (CHWs) in interdisciplinary care teams.1 CHWs – also known as promotoras de salud, community health representatives, community health

Self-management support is “assistance provided by clinicians and public health practitioners to enhance an individual’s self-efficacy in managing one or more chronic conditions.” 1Self-management support increases individuals’ skills and confidence in managing their health problems, including regular assessment of progress

Managing transitions is a key aspect of care coordination and helps ensure that participants undergo a seamless transition from one setting to another. These transitions may be from one health care setting to another, from a health care setting to

Navigation services can help providers deliver more integrated care to people with serious mental illness (SMI) and chronic or complex medical conditions. Such services include linking individuals (and their natural supports) with essential health and community services. Navigation coordinates care

Integrated behavioral health provides care in a single setting, often primary care, for both medical and behavioral health conditions. Primary care and behavioral health clinicians collaborate to provide person-centered care for a specific population. Care can be focused on mental

Among beneficiaries dually eligible for Medicare and Medicaid, 41% have a mental health condition compared to 16% of Medicare-only beneficiaries.1 One in four older adults experience a mental health condition, yet older adults underutilize behavioral health services.2,3   Older Americans may

Individuals who are dually eligible for Medicare and Medicaid are more likely than other Medicare beneficiaries to have a mental health diagnosis as well as other complex and chronic conditions.1 Approximately 50% of dually eligible adults aged 18 to 64