vidual or legally acting on the individual’s be-
half, community-based service professionals, 
and health care professionals providing care to 
the older individual, in the design and imple-
mentation of an individualized, individual-cen-
tered service and support plan, through which 
the services and supports will be provided in a 
manner free from conflicts of interest; 
‘‘(iii) integrates services and interventions 
that are implemented, monitored, and evaluated 
for effectiveness using an evidence-based proc-
ess, which typically involves a designated lead 
care coordinator and involves feedback from the 
older individual; 
‘‘(iv) includes activities that aim simulta-
neously at meeting individual and family needs 
and preferences, building on individual capabili-
ties, and improving outcomes and systems of 
care; 
‘‘(v) includes provision of some or all of 
the services and activities described in clauses 
(i) through (iv) by trained professionals em-
ployed by or under a contract with— 
‘‘(I) area agencies on aging; 
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‘‘(II) Aging and Disability Resource 
Centers; or 
‘‘(III) other service providers, includ-
ing in-home service providers; and 
‘‘(vi) is not furnished to directly diagnose, 
treat, or cure a medical disease or condition.’’. 
SEC. 4. FUNCTIONS OF THE ASSISTANT SECRETARY. 
Section 202(a) of the Older Americans Act of 1965 
(42 U.S.C. 3012(a)) is amended— 
(1) in paragraph (27), by striking ‘‘and’’ at the 
end; 
(2) in paragraph (28), by striking the period 
and inserting ‘‘; and’’; and 
(3) by adding at the end the following: 
‘‘(29)(A) encourage, provide technical assist-
ance to, and share best practices with, States, area 
agencies on aging, Aging and Disability Resource 
Centers, and service providers to carry out outreach 
and coordinate activities with health care entities in 
order to assure better care coordination for individ-
uals with multiple chronic illnesses; and 
‘‘(B) coordinate activities with other Federal 
agencies that are working to improve care coordina-
tion and developing new models and best practices.’’. 
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SEC. 5. ORGANIZATION. 
Section 305(a) of the Older Americans Act of 1965 
(42 U.S.C. 3025(g)) is amended— 
(1) in paragraph (2), by striking ‘‘and’’ at the 
end; 
(2) in paragraph (3), by striking the period and 
inserting ‘‘; and’’; and 
(3) by adding at the end the following: 
‘‘(4) the State agency shall promote the devel-
opment and implementation of a State system to ad-
dress the care coordination needs of older individuals 
with multiple chronic illnesses, and shall work with 
acute care providers, area agencies on aging, service 
providers, and Federal agencies to ensure that the 
system uses best practices and is evaluated on its 
provision of care coordination.’’. 
SEC. 6. AREA PLANS. 
Section 306(a) of the Older Americans Act of 1965 
(42 U.S.C. 3026(a)) is amended— 
(1) in paragraph (4)(B)(i)(VII) by inserting 
‘‘with multiple chronic illnesses or’’ after ‘‘older indi-
viduals’’; 
(2) in paragraph (6)(D), by inserting ‘‘(includ-
ing acute care providers)’’ after ‘‘service providers’’; 
(3) in paragraph (16), by striking ‘‘and’’ at the 
end; 
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(4) in paragraph (17) by striking the period 
and inserting ‘‘; and’’; and 
(5) by adding at the end the following: 
‘‘(18) provide assurances that the area agency 
on aging will— 
‘‘(A) identify existing (as of the date of 
submission of the plan) care coordination pro-
grams and systems; 
‘‘(B) identify unmet community need for 
care coordination; 
‘‘(C) facilitate the development and imple-
mentation of an area-wide system to address 
the care coordination needs of older individuals 
with multiple chronic illnesses; and 
‘‘(D) work with acute care providers, serv-
ice providers, and Federal and State agencies to 
ensure that the system uses best practices in its 
provision of care coordination.’’. 
SEC. 7. STATE PLANS. 
Section 307(a) of the Older Americans Act of 1965 
(42 U.S.C. 3027(a)) is amended— 
(1) in paragraph (2)(A), by inserting ‘‘care co-
ordination,’’ after ‘‘information and assistance,’’; 
(2) in paragraph (17), by striking ‘‘and develop 
collaborative programs, where appropriate,’’ and in-
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serting ‘‘, ensure care coordination, and (where ap-
propriate) develop collaborative programs,’’; 
(3) in paragraph (18), in the matter preceding 
subparagraph (A), by inserting ‘‘and ensure care co-
ordination that integrates long-term care services 
and other care services,’’ before ‘‘for older’’; 
(4) in paragraph (23), by striking ‘‘with other 
State services’’ and inserting ‘‘with other Federal 
and State health care programs and services’’; and 
(5) by adding at the end the following: 
‘‘(31) The plan shall provide assurances that 
the area agencies on aging in the State will facilitate 
the area-wide development and implementation of an 
area-wide system to address the care coordination 
needs of older individuals with multiple chronic ill-
nesses, and work with acute care providers, service 
providers, and other Federal and State agencies to 
ensure that the system uses best practices and is 
evaluated on its provision of care coordination.’’. 
Æ 
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