every member of the team to the full capacity of his 
or her training and skills. 
(7) The Patient Protection and Affordable Care 
Act (Public Law 111–148) emphasizes the need for 
improving care and lowering costs by better coordi-
nation of care and integration of services, particu-
larly for consumers with multiple chronic conditions. 
This has required developing new models of care for 
those receiving long-term services and supports. 
SEC. 3. DEMONSTRATION PROGRAM ON CARE COORDINA-
TION AND SERVICE DELIVERY. 
Title III of the Public Health Service Act is amended 
by inserting after section 330M of such Act (42 U.S.C. 
254c–19) the following: 
‘‘SEC. 330N. DEMONSTRATION PROGRAM ON CARE COORDI-
NATION AND SERVICE DELIVERY. 
‘‘(a) ESTABLISHMENT
OF DEMONSTRATION PRO-
GRAM.— 
‘‘(1) IN
GENERAL.—The Secretary, acting 
through the Administrator of the Health Resources 
and Services Administration, shall carry out a dem-
onstration program in accordance with this section. 
Under such program, the Secretary shall award 
grants to eligible entities to carry out demonstration 
projects that focus on care coordination and service 
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delivery redesign for older adults and people with 
disabilities who have chronic illness or are at risk of 
institutional placement by— 
‘‘(A) designing and testing new models of 
care coordination and service delivery that 
thoughtfully and effectively deploy direct-care 
workers in advanced roles to improve efficiency 
and quality of care for older adults and people 
with disabilities; and 
‘‘(B) giving direct-care workers opportuni-
ties for career advancement through additional 
training, an expanded role, and increased com-
pensation. 
‘‘(2) DIRECT-CARE WORKER.—In this section, 
the term ‘direct-care worker’ has the meaning given 
that term in the 2010 Standard Occupational Classi-
fications of the Department of Labor for Home 
Health Aides [31–1011], Psychiatric Aides [31– 
1013], Nursing Assistants [31–1014], and Personal 
Care Aides [39–9021]. 
‘‘(b) DEMONSTRATION PROJECTS.—The demonstra-
tion program under this section shall be composed of 4 
demonstration projects, as follows: 
‘‘(1) Two demonstration projects shall focus on 
using the abilities of direct-care workers to promote 
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smooth transitions in care and help to prevent un-
necessary 
hospital 
readmissions. 
Under 
these 
projects, direct-care workers shall be incorporated as 
essential members of interdisciplinary care coordina-
tion teams. 
‘‘(2) Two demonstration projects shall focus on 
maintaining the health and improving the health sta-
tus of those with multiple chronic conditions and 
long-term care needs or on training direct-care work-
ers to take on greater responsibilities related to spe-
cific diseases, including Alzheimer’s disease and de-
mentia, congestive heart failure, and diabetes. Under 
these projects, direct-care workers shall assist in 
monitoring health status, ensuring compliance with 
prescribed care, and educating and coaching the 
older adults and people with disabilities involved, as 
well as any family caregivers and other members of 
the care team. 
‘‘(c) ELIGIBLE ENTITY.—In this section, the term 
‘eligible entity’ means a consortium that consists of— 
‘‘(1) at least 1— 
‘‘(A) skilled nursing facility or other resi-
dential long-term care provider; or 
‘‘(B) home health and personal care service 
provider; and 
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‘‘(2) at least 1— 
‘‘(A) hospital or health system; 
‘‘(B) labor organization or labor-manage-
ment partnership; 
‘‘(C) community-based aging and disability 
services provider; 
‘‘(D) patient-centered medical home; 
‘‘(E) federally qualified health center; 
‘‘(F) managed care entity, including a 
managed health and long-term care program; 
‘‘(G) entity that provides health services 
training; 
‘‘(H) State-based public entity engaged in 
building new roles and related curricula for di-
rect-care workers; or 
‘‘(I) any other entity that the Secretary 
deems eligible based on integrated care criteria. 
‘‘(d) APPLICATION.—To be eligible to receive a grant 
under this section, an eligible entity shall submit to the 
Secretary an application at such time, in such manner, 
and containing such information as the Secretary may re-
quire, which shall include— 
‘‘(1) a description of the care coordination and 
service delivery models of the entity, detailed on a 
general, organizational, and staff level; 
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‘‘(2) a description of how the demonstration 
project carried out by the entity will improve care 
quality, including specific objectives and anticipated 
outcomes that will be used to measure success; and 
‘‘(3) a description of how the coordinated care 
team approach with an enhanced role for the direct- 
care worker under the demonstration project will in-
crease efficiency and cost effectiveness compared to 
past practice. 
‘‘(e) PLANNING AWARDS UNDER DEMONSTRATION 
PROGRAM.— 
‘‘(1) IN GENERAL.—Each eligible entity that re-
ceives a grant under this section shall receive a 
grant for planning activities related to the dem-
onstration project to be carried out by the entity, in-
cluding— 
‘‘(A) designing the implementation of the 
project; 
‘‘(B) identifying competencies and devel-
oping curricula for the training of participating 
direct-care workers; 
‘‘(C) developing training materials and 
processes for other members of the interdiscipli-
nary care team; 
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