(Chronic Care Initiatives in HMOs, undated; Scott and Robertson, 1995). The objective is to reduce the cost of care for these patients and to improve health status "through better preventive medicine, maintenance of independent living and improvement in access to care" (Scott and Robertson, p. 1) and improved patient and provider satisfaction. The model uses a multidisciplinary team that meets with groups of 12 to 30 patients every 4 to 6 weeks. The session provides "medical and functional assessment, group education, coordination of services between primary care and other health professionals, and an opportunity for the group to socialize with each other" (Group Health Association of America, 1995a; Scott and Robertson, 1995, p. 1).

Integration of Acute and Long-Term-Care Services

Patients needing chronic care services require a full range of treatment modalities that often span areas covered by acute and long-term-care insurance coverage. There have been several demonstrations to integrate acute and long-term-care services, most notably the Program of All-Inclusive Care for the Elderly (PACE)/On Lok projects and the Social Health Maintenance Organizations. These programs have tried to improve coordination by bridging through common financing, acute-care benefits, and home and community-based long-term-care services.

The On Lok Senior Health Services was initially developed in 1971 as an adult day health center. It later received Section 1115 waivers that enabled it to receive capitation payments to provide comprehensive medical and social service benefits (e.g., primary medical and nursing care, day health, hospitalization, transportation, meals, and in-home services) through multidisciplinary teams to a nursing home-certified population. On Lok has since been replicated throughout the country through PACE. In general, although members of the On Lok/PACE projects have severe impairments, they are not as dependent in activities in daily living as nursing home residents (Weiner and Skaggs, 1995).

The Fallon Healthcare System is the first HMO to establish a PACE site, the Elder Service Plan (ESP) (Group Health Asso-

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