“Integration” of health and social care and related services (e.g. mental health, housing and transportation) for chronically ill and disabled populations, especially for the frail elderly, became one of the buzzwords of the 1990s. It was during this period that serious interest in the provision of integrated care proliferated in both the policy and practice arenas, particularly in Western Europe. The term “integrated care,” like a Rorschach test,1 has many meanings.2 For the purposes of this discussion, we consider integrated care to be a discrete set of techniques and organisational models designed to create connectivity, alignment and collaboration within and between the cure and care sectors at the funding, administrative and/or provider levels.3 The goals are to enhance quality of care and quality of life, consumer satisfaction, and system efficiency for patients with complex problems cutting across multiple sectors and providers [1–4].4

Whether old or young, people with chronic illnesses and disabilities are an especially vulnerable group, and are the most likely to benefit from integrated care. For both patients and family carers, the incurable, unpredictable, and costly nature of these conditions presents difficult challenges in terms of arranging care; following treatment regimens and controlling symptoms; coping with changes and daily intrusions; preventing and managing crises; and, normalizing relationships; as well as other activities necessary for maintaining physical health and social independence [5]. The challenges on the provider side are daunting as well. Regardless of the country, system or setting, difficulties are often encountered with obtaining comprehensive assessments, putting together service packages, monitoring changes in health status, working within existing funding constraints, and coordinating care from a mix of providers through periods of acuity, maintenance, rehabilitation and transition [6].

The ability of patients and providers to overcome these challenges is compounded by numerous shortcomings found in health and social care systems in most industrialized nations. In the United States, the delivery of acute (health) and long-term (social) care is often fragmented and uncoordinated [7]. Services are the responsibility of many jurisdictions, agencies and professionals. The various components of the health system, whether based in the home, community, outpatient or institutional setting, work in parallel with separate funding streams and budgets, under disparate, and frequently conflicting regulations, and with distinctly different clinical roles, responsibilities and approaches [8]. Moreover, the long-term care sector is overly medicalised and institutionally biased. The absence of a single, community-based system or institution with broad clinical and financial responsibility and accountability creates overlaps, leaves important needs unmet, and is partly responsible for unnecessary hospitalization, institutionalization, less than optimum quality, and poorly controlled costs. The economic burden of providing chronic care is enormous. This is especially the case in the United States, which lacks a universal health care system. The patchquilt of American financing programs, including Medicare (the federal health insurance program for the elderly and disabled), Medicaid (the federal and state-sponsored, means-tested health care program for low-income individuals), and private insurance, is inadequate to cover the often-catastrophic expenses of chronic illness [9]. Patients in these circumstances are often forced to pauperize themselves to get needed coverage and care.

Chronic disease represents the highest cost and fastest-growing segment of American health care. These costs have been estimated to be three to five times higher than for non-chronically ill patients [10–13]. In economic terms, these costs are staggering; they make up the largest share of total health care dollars spent in the United States [13, 14]. Between 70 and 80% of national expenditures on personal health care ($600 billion annually) can be attributed to the chronically ill [13, 15]. According to The Institute for Health and Aging [13], in 1987 (the most recent study of this nature), taxpayers paid 40% of the direct medical costs of chronic care, excluding nursing home care, through Medicare, Medicaid and other public programs. Private insurance paid about one-third of these expenditures, and individuals paid about 20% of these expenses out-of-pocket. By 2030, unless new systems of care are created, chronic care costs alone are estimated to amount to nearly $800 billion (in 1990 dollars) [13].

The prevailing belief in the United States is that integrated care has the capacity to solve many of the above-mentioned problems by improving care co-ordination and continuity; streamlining disjointed services and systems; eliminating duplication; reducing administrative and service costs; and, by promoting more equitable distribution of resources [16]. Such efforts are believed to ultimately provide more appropriate and higher quality care. These expectations for integrated care are shared, in large part, by other countries, such as England and the Netherlands [2]. Consequently, integrated care projects of various types are beginning to blossom internationally.5 The United States, which has led experimentation with such models for over two decades, is unique, however, in its commitment to fully integrated care (a variant of “managed care”) for the frail elderly.

The purpose of this article is to explore the concept of fully integrated care, and critically examine two American models for the frail elderly (the social health maintenance organization or Social HMO and the program of all-inclusive care for the elderly or PACE) in organizational, efficiency and quality terms. Our intention is to provide insight as to how these systems work, their outcomes, and the lessons learned.

Our methodological approach was to systematically compile and synthesize existing qualitative and quantitative data about integrated care in general, and fully integrated care models for the elderly in the United States, in particular, from reports and policy analyses published by governmental and non-governmental organizations, journal articles retrieved from Medline, HealthSTAR, and other sources. To ensure a comprehensive collection of materials, we first conducted a computerised search of aforementioned databases from January 2000 through March 2000, and then engaged several experts in the field in structured discussions regarding the availability of data and resources. Research articles from the period of 1974–present were examined if they met search criteria, including variations of the terms Social HMO and PACE; integrated care; and Medicare HMO.

Below, we first present a conceptual discussion about fully integrated care and its close connection to managed care. An appreciation of the relationships between these two overlapping frameworks is essential to understanding the context, organization and performance of the two American models that are the focus of this analysis. Next, we critically examine these specific models by comparing and contrasting them. We conclude this article with a review of current knowledge, and of the policy and practice implications for the development and evaluation of fully integrated approaches.

According to Leutz, there are three levels of integration: (1) linkage; (2) co-ordination; and, (3) full integration. These levels can be described as a continuum. Located at one end of the continuum is “linkage.” This is a minimalist, least-change approach to integrated care, which operates within the context of existing, fragmented systems. “Full integration” lies at the other end of the continuum. This represents the complete overhaul and consolidation of all or most responsibilities, resources and funding for patient management/care for a particular population. These levels are described more fully below:

We hypothesise that the level of integration with respect to the above factors increases along a continuum, from linkage to full integration. These hypothetical relationships are shown in Table 1. A zero (0) denotes that the particular model has no impact on the level of integration for the corresponding element or function. A single check (√) denotes that the particular model has some impact on the corresponding element or function; three checks (√√√), the highest impact.

Table 1 Hypothetical levels of integration in models of integrated care

For the most part, fully integrated models are examples of a type of American managed care organisation referred to as the health maintenance organisation (HMO). HMOs represent the purest organisational form of managed care, dating back to the late-1920s. Although the term has a variety of interpretations, there is general agreement that this health care entity, at the very least, combines both the financing and delivery systems [26].9 Today, HMOs are the predominant form of health care coverage in the United States [27]. As a result of the widespread development of HMOs, the interest in, and willingness among federal and state policymakers and providers to experiment with fully integrated models for the frail elderly, has grown significantly [28]. Box 2 identifies the key features of fully integrated models, most of which are shared with HMOs.10

With respect to the discussion of outcomes, several issues should be pointed out. First, the two programs (the social health maintenance organisation and the program of all-inclusive care of the elderly) have been in operation for nearly two decades, and therefore, a substantial body of literature exists. Second, although information on these models is available, it is often not comparable, thus limiting our ability to make comparisons across the two programs. Third, definitive evidence on the effectiveness and efficiency of the programs is lacking [30]. However, we believe that enough information is available to begin examining critical factors and effects.

Table 2 provides an overview of the two models in terms of six basic characteristics: (1) status (operational and legal); (2) targeting; (3) benefit package; (4) financing; (5) delivery system and clinical management; and (6) enrolment.

Table 2 Basic characteristics of two American models

Each of the models is elaborated on below. Key program components are described first. This is followed by a case presentation depicting the process of care, using a different hypothetical patient for each model. Evaluation results, including findings on quality and cost impacts, are then discussed. Finally, the lessons learned will be briefly summarised.

The general aspects of the Social HMO's delivery system and clinical management are summarised in Table 2. As the name implies, the Social HMO has its roots in the conventional, “acute-oriented” HMO model. Thus, the fundamental challenge in designing the Social HMO has been in grafting a long-term care support system to a medical care delivery system. Each of the Social HMO sites were given flexibility to accomplish this goal in their own manner. Differences between sites reflect the particular orientation and experience of the sponsoring entities. Two of the sites (Medicare Plus II and Seniors Plus, the site that closed) are sponsored by longstanding, large-scale HMOs with Medicare programs. The other two (Elderplan and SCAN Health Plan) are sponsored by long-term care providers. Whereas Medicare Plus II and Seniors Plus emphasised the building of linkages with and between institutional- and community-based long term care providers, Elderplan and SCAN Health Plan focused on developing a managed care infrastructure, as well as medical care capabilities.

Other significant differences between the sites relate to program auspices and size. Elderplan and SCAN Health Plan were specifically formed to operate the Social HMO on a stand-alone basis; this was their sole mission. Medicare Plus II and Seniors Plus, on the other hand, operated as separate units within acute-oriented HMOs with extensive, pre-existing enrolments (with hundreds of thousands of non-Social HMO enrolees). All sites were required to enrol a minimum of 5000 individuals (a number considered by the original designers to be important from an economy of scale perspective), although this target proved difficult to meet initially, in some cases. In both examples, however, the implementation of the model depended on managing complex provider relationships and care arrangements across a relatively diffuse organisational network.

Care management, however, is a central feature at all four sites. This co-ordination function, which is the responsibility of a specialised unit at each site, allocates the long-term care benefit to enrolees who meet the above eligibility criteria. Members of the care management team include nurses, social workers and other health professionals. Their tasks include comprehensive assessment, care planning (for long term care services and other expanded benefits), service authorisation and arrangement, and ongoing patient monitoring and follow-up. A multidisciplinary form of team care is used, whereby care managers and providers share patient information and discuss and recommend care decisions.

There are two unique aspects of this care management system that are important to note. First, assessment and care planning activities include the elderly enrolee and family carers, as well as the primary care physician. Second, needed long term care services are delivered by providers under contract with the Social HMO. Thus, access to quality care (according to agreed-upon standards) is assured, as is payment to the provider.

Several clinical management tools are employed in the care management function described above. The Health Status Form (HSF) is a screening instrument that is conducted on enrolment and periodically thereafter, designed to identify enrolees at-risk through self-reported health status. The form collects information on current medical complaints and physical problems, and ongoing care. It is used by the Social HMO as part of a population-based, high-risk screening process to identify unmet medical and social needs that may require immediate attention, including the need for long term care. The Comprehensive Assessment Form (CAF) is a multidimensional geriatric assessment tool that is used to evaluate the enrolee's long term care needs, as well as to determine level of impairment (and, thus, eligibility for coverage by the long term care benefit). This form is administered by a care manager in the patient's home. Referrals for comprehensive assessment come from two major sources: (1) screening from the Health Status Form; and, (2) requests made by physicians (especially primary care physicians), family carers, and enrolees. Care managers may also conduct such assessments when called for by clinical judgement. The Comprehensive Care Plan is then developed by the care manager and primary care physician, in collaboration with the enrolee and family carers. This care plan lists specific long term care goals for the patient, as well as the services needed to improve their health and functional status. The plan is also used as the basis of assigning service responsibility and authorising care.

There is a substantial body of literature on the demonstration, which addresses all aspects of the model.14 The results are complex, and shrouded in controversy, primarily because of disagreements related to the evaluation design, specifically the nature of the comparison groups used [33].15 For example, researchers involved in the evaluation of PACE (see section 3.3 below), argue that the comparison group used to evaluate outcomes in the Social HMO demonstration was biased [57, 66]. Nonetheless, most would agree with the overall finding that the model fell short of fulfilling initial expectations, but demonstrated the value of the approach and its feasibility. The following is a general summary of major findings with regard to program outcomes:

There are, however, alternative explanations. With respect to increased inpatient hospital use, Boose [44] and Brody [47] both suggest that this utilisation pattern reflects, in part, better medical detection and follow-up, at least in two of the Social HMOs (Medicare Plus II, and Seniors Plus). Furthermore, there is contradictory evidence at the site-specific level regarding short-term nursing home use. According to Boose [44], Medicare Plus II enrolees spent approximately 25% fewer days in nursing homes, and that this was achieved by more effective transitions between the hospital, nursing home, and community settings. Moreover, Brody [47] observes that the package of home- and community-based services covered by Seniors Plus, including the co-ordinated and more flexible access to personal assistance services, respite and adult day health care, had an offsetting effect on the rate of nursing home use.

Enrolment was also slower than anticipated, resulting in higher than expected marketing costs [39]. Obstacles to enrolment included the lack of willingness on the part of many elderly to change primary care physicians and/or managed care plans, as well as the newness of the program. Finally, the queuing method used to control selection bias proved to be a cumbersome administrative burden; this approach is no longer used by the remaining sites.

The general attributes of the delivery and clinical management systems in PACE are summarised in Table 2.

As mentioned, PACE emphasises the day health centre as the primary setting for the delivery of most, if not all covered services. The setting simultaneously defines the delivery system, and serves as an enabling component critical to the model's efficiency and effectiveness. This narrowing of the organisational and delivery system focus is in stark contrast to the Social HMO model, which depends on making and maintaining connections with providers located throughout the broader community health system.

Average adult day health centre attendance is 10 days per month (ranging from 7.6 days to 14.8 days) [53]. For these program participants, the use of the centre offers substantial opportunities for close patient contact, tight clinical oversight, the “geriatricisation” of care, intense collaboration among providers, and cost savings [55–58]. This potential is amplified by the relatively small size of the patient population served at each site (approximately 300). The geriatric approach, which incorporates the basic principles of geriatric medicine, is at the core of the model. This includes emphasis on primary care, multidisciplinary teamwork, psychosocial support, and prevention (e.g. immunisations, medication monitoring, nutritional assessment, depression screening, and periodic evaluation of home safety) [52].

Unlike the Social HMO, which depends upon a less structured form of multidisciplinary communication and collaboration between the care manager, primary care physician, and other providers, PACE uses a full-blown interdisciplinary approach to team care. The team, consisting of primary care providers (both physicians and nurse practitioners), adult day health centre and home care nurses, personal care assistants, social workers, rehabilitation and recreation therapists, nutritionists, and transportation workers, operates collectively in its care management role [59]. Team members jointly assess patient needs, formulate treatment plans, ensure that required services are delivered, monitor patient status and care, adjust services, and track quality and costs [52]. Considerable staff time is devoted by team members to formal and informal idea and information exchange; formal meetings account for approximately 8-hours weekly per participant [59]. The structure and process of team care in this model is firmly grounded in what has been referred to as a “geriatric interdisciplinary team”. Williams and colleagues [60], who describe this particularly effective type of team care, observed that the group decision-making and consensus building inherent in such teams, facilitates better care management and service performance.

The process of care starts with the use of a comprehensive set of assessment tools. This is part of an automated data system (DataPACE), which was designed specifically for the program and is used across all sites. This battery of discipline-specific instruments enable physicians, nurses and social workers to independently collect information on all aspects of patient health status and functioning. These data, in addition to information collected from supplementary tools used by the various sites (e.g. state-mandated nursing home eligibility screen), are organised for care planning purposes by each of the programs at the beginning at intake/enrolment process. This patient profile forms the basis of the care plan, which is periodically updated. The care plan is used to “order” services, and serves as the bridge to both internal and external resources.

Enrolment in the program was found to be associated with a large decrease in hospital use, both in terms of admissions and days (for admissions, 50% less than the comparison group; for days, about 3–4 fewer days). Similarly, enrolees were less likely than the comparison group to be admitted to a nursing home, and spent fewer days when admitted (for admissions, 20% less; for days, an average of 16 fewer days). Patients in the program also used substantially more ambulatory care services, including outpatient medical and therapeutic care, as well as home- and community-based social care, than comparisons (i.e. 93% vs. 74%, respectively, had at least one visit in the first 6-months).

These results suggest that the model was successful in managing frail elderly patients in the community, and off-setting more expensive inpatient services [66, 67]. However, some caution may be in order regarding these two interpretations, due to the non-randomised nature of the comparison group used [68].

Chatterji et al. [66] found that program enrolees have a significantly higher probability of reporting “good” or “excellent” health, after 6-months, adjusting for health status at enrolment (43 vs. 37% for the comparison group). Evidence for a higher quality of life was also found; 72% of enrolees versus 55% of the comparison group reported that their lives were more satisfying. Pryor [63] also found similar impacts at the Rochester, New York site. Furthermore, enrolees expressed greater confidence in their ability to take control of their lives and deal with day-to-day problems, and were more inclined than individuals in the comparison group to participate in social, religious and recreational activities. Results in terms of physical functioning are inconsistent. As far as the quality of life of carers, no statistically significant differences between groups were found. Lastly, at 6-months, program enrolees were approximately 15% more likely to report being “very satisfied” with overall care arrangements than individuals in the comparison group. In addition, the South Carolina study [62] found that both patients and their carers had a high degree of satisfaction with services, that their quality of life had improved, and most (63%) felt that the medical care in the program, was better than received in the traditional system.

The delivery of care in the program is organised around regular enrolee participation in an adult day health centre. This approach appears very effective for those frail elderly who are willing and able to receive care and support in this unique setting. Nonetheless, many individuals are not attracted to the prospect of regular day care attendance. Consequently, existing programs are exploring more flexible possibilities, including the greater use of in-home care [30]. Such alternatives, however, fail to address historical patient concerns related to physician choice, and the need to switch providers in order to join the program.

The intensive focus on geriatric care and interdisciplinary teamwork explains, in large part, the efficiency and quality outcomes that are positively associated with the model. However, these rigorous elements, as important as they are, may be beyond the resources and experience of many providers. The growing awareness of, and interest in, geriatrics and gerontology in the health and social service professions, should begin to close this gap.

The small size of the program sites (averaging about 300 enrolees) encourages and enables intensive, responsive interaction on an on-going basis between providers, patients, and family carers. This close personal attention fits well with patients affected by complex, changing and unpredictable chronic, disabling conditions. However, this strength is also a limitation. The broad application of the model to an entire frail elderly population, especially one as large as in the United States, has enormous economic and resource consequences. In light of this, perhaps the essential features of the model could be effectively incorporated into existing, much larger Medicare HMOs, or other emerging health care delivery systems.

Lastly, PACE has been unable to attract frail elderly persons who are not covered by Medicaid (in addition to Medicare), but who are otherwise eligible for the program and could benefit substantially. This is because of the very high cost of the private premium, the result of caring for only nursing home-type patients with very resource-intensive and expensive needs. Even though these premiums are less than actual, out-of-pocket costs, many elderly are still unwilling, or unable to carry this financial burden. The implication is that the program should consider developing alternative service packages that may be more appealing to this segment of the frail older population.

The purpose of this article was to examine fully integrated models of care, and analyse them from conceptual and real-world perspectives within the broader context of the integrated care continuum. This approach, however, does have its limitations. The most obvious limitation is that it does not consider, in any detailed way, the promise and potential of either the co-ordinated or linkage models, whether from the point of view of outcomes, technical feasibility or acceptance. Another limitation is the lack of comparable data. As mentioned earlier, although a substantial body of literature about the Social HMO and PACE exists, it rarely presents findings or lessons learned in a uniform fashion, making comparisons difficult. We attempted to draw some conclusions from the existing literature, and offer recommendations for how future studies can ensure greater generalizabilty.

It is the opinion of the authors that complex systems problems demand complex systems solutions. This is the rationale behind fully integrated models of care for the frail elderly. To explore this hypothesis, we examined two major American examples of fully integrated care, namely the Social HMO and PACE. Our analysis strongly suggests that this particular model is not only feasible, but offers significant potential to improve the delivery of care and its outcomes for patients who have conditions that are, at once, complicated, debilitating, clinically challenging, and very costly.

Despite the overall feasibility of this model, our analysis highlights critical differences between the two programs in terms of their design, implementation, and performance. Clearly, these differences are closely linked to the relative degree of success achieved by each program. Although further research is needed to more clearly elucidate why and how fully integrated models such as these, work, we believe nonetheless, that meaningful clues can be discerned from the existing data.

There are several elements which we have identified from our analysis, that appear to be related to both the efficiency and effectiveness of fully integrated systems of care for the frail elderly:

• longitudinal care management, spanning time, setting and discipline;
• intensive, interdisciplinary team care;
• geriatric philosophy and focus, including a central role for the primary care physician;
• organised provider and clinical arrangements to achieve horizontal and vertical alignment;
• appropriate targeting, i.e., serving the right population and keeping the size of the patient panel within manageable limits; and,
• mechanisms to pool funding streams to assure administrative and clinical flexibility.21

While each of these integrating factors are essential on their own, we have reached two conclusions about their inter-relationships. First, the synergy among and between these critical elements is what makes fully integrated care possible. Second, the existence of a single, accountable organisational structure allows for their optimum impact.

The promise of fully integrated care, as discussed in-depth here, has spurred the further development of new and more refined American models. At last count, at least 25 states are in various stages of program development [69]. Providers are also actively engaged in this process of innovation. Two promising examples include the continuing care network under development by several hospital-based health systems [70], and the chronic care organisation, a home care-based integrated delivery system which was just launched in New York City [6].

An unanswered question is whether or not such fully integrated models of care can be effectively replicated in the health and social care systems of other countries. Even though we face similar challenges with respect to the growing population of frail elderly citizens, there are significant differences in terms of the social, cultural, political and economic contexts within which chronic care services are paid for, organised, and delivered. However, this does not seem to be a totally insurmountable barrier, witness the planning and development of the system of integrated care for the frail elderly (known in French as SIPA) in Quebec, Canada [71].

A final lesson from this American experience relates to the crucial role of evaluation in measuring program impact. Findings from such research have broad implications. Therefore, it is important to recognise that the complexities involved with fully integrated models of care make outcome evaluation difficult. Moreover, as the experience with the Social HMO and PACE indicates, the design of an evaluation (including the choice of methods and tools) must reflect the shared perspectives of the major stakeholders. Without such consensus, there is high likelihood that evaluation results will be conflicting, as well as difficult to interpret and apply. By moving in this direction, we will be contributing in a positive way to the evolution of—what we believe should be called—evidence-based integrated care in both policy and practice.

The authors would like to thank Walter Leutz, PhD of Brandeis University; and, Meg Sherlock, RN, MA, CS, Rose Madden-Baer, RN, MSN, CS, Karen Tokar, RN, Jonathon Shankman, MPH, MBA, Carolyn Abruzzo Vella, MS and Tim Ford, MBA, from Metropolitan Jewish Health System and the Institute for Applied Gerontology, for their valuable help with several stages of this paper, including their thoughtful review.

METROPOLITAN JEWISH HEALTH SYSTEM – www.mjhs.org

Metropolitan Jewish Health System (MJHS) is a highly integrated system that provides a continuum of care for aging and chronically ill individuals of all ages. MJHS' mission meets the diverse needs of the community, and its unique structure defines the integrated way that MJHS operates, delivers services and anticipates future needs. MJHS sponsors Elderplan, Inc., one of the Social HMOs discussed in this article.

HEALTH CARE FINANCING ADMINISTRATION – http://cms.hhs.gov/

The Health Care Financing Administration (HCFA), is the federal agency that administers Medicare, Medicaid and the State Children's Health Insurance Program (SCHIP). HCFA provides health insurance for over 74 million Americans through Medicare, Medicaid and SCHIP. The majority of these individuals receive their benefits through the fee-for-service delivery system, however, an increasing number are choosing managed care plans. In addition to providing health insurance, HCFA also performs a number of quality-focused activities, including regulation of laboratory testing (CLIA), surveys and certification of health care facilities (including nursing homes, home health agencies, intermediate care facilities for the mentally retarded, and hospitals), development of coverage policies, and quality-of-care improvement.

To ensure public and expert involvement in running our programs, HCFA maintains a number of chartered advisory committees. These committees, whose meetings are open to the public, are used to provide advice or make recommendations on a variety of issues relating to HCFA's responsibilities and activities.

NATIONAL PACE ASSOCIATION – www.natlpaceassn.org

The National PACE Association (NPA) is a nonprofit membership organisation representing the interests of almost 60 organisational members. These organisations share the goal of promoting the availability of quality, comprehensive, and cost-effective health care services to frail older adults through the Program of All-inclusive Care for the Elderly (PACE) and similar models of care.

NATIONAL CHRONIC CARE CONSORTIUM – www.nccconline.org

The National Chronic Care Consortium (NCCC) is a mission-driven organisation of leading-edge health networks dedicated to transforming the delivery of chronic care services, who share a vision of integrated care for individuals with chronic health conditions, from the time of earliest condition awareness until problem resolution or death. This vision emanates from a recognition that the primary business of the healthcare industry is changing from acute care to chronic care. People with serious chronic conditions are healthcare's highest-cost and fastest-growing service group. Current administration, financing, and service delivery methods are increasingly ineffective and inefficient in addressing the multidimensional needs of people with chronic conditions.

Dennis L. Kodner, Knowledge and Innovation, Metropolitan Jewish Health System & Executive Director, Institute for Applied Gerontology.

Corinne Kay Kyriacou, Institute for Applied Gerontology.

Dennis L. Kodner, PhD is Senior Vice President, Knowledge & Innovation at Metropolitan Jewish Health System, New York City, and Executive Director of its Institute for Applied Gerontology. Dr. Kodner is on the faculties of New York Medical College, New York University, and Maastricht University. His policy, research and practice interests include long term care financing and service delivery, chronic illness care, managed care and integrated care systems for vulnerable populations, and comparative health systems. He served as the first director of Elderplan, the social health maintenance organisation sponsored by Metropolitan Jewish Health Center.

Corinne Kay Kyriacou, PhD is Director of Research in the Center for Research and Population Health at the Institute for Applied Gerontology, New York City. She was a Fellow of the Agency for Health Care Policy and Research, and received her doctorate in health services research from the Heller Graduate School at Brandeis University. Dr. Kay Kyriacou's research and policy interests include long-term care organisation and quality, consumer directed care, palliative care, and integrated systems of care for the frail elderly.