PACE integrates Medicare and Medicaid financing to provide comprehensive delivery of those programs’ services to individuals age 55 and older who have been certified as eligible for nursing home care by a state under Medicaid. PACE providers are, or are a separate part of, government entities or are not-for-profit private or public entities that provide PACE services to eligible individuals. PACE services include, but are not limited to, all Medicare services and all Medicaid services as specified in the state plan. Adult day care, medical treatment, home health and personal care, prescription drugs, social services, restorative therapies, respite care, and hospital and nursing home care when necessary are all required services under PACE. For most individuals, the comprehensive services offered by PACE allow them to live in their homes. CMS requires that each PACE provider operate an adult day center for its beneficiaries. WPP is a state-sponsored program that integrates Medicare and Medicaid financing to provide comprehensive delivery of those programs’ services to individuals age 55 and older and individuals age 18 and older with physical disabilities who have been certified by Wisconsin as eligible for nursing home care. To deliver WPP services, the state contracts with organizations to provide eligible individuals with primary, acute, and long- term care services; prescription drugs; rehabilitation services and physical therapy; adult day care; nursing home care; durable medical equipment and supplies; and other services such as meal delivery and transportation to medical appointments. The comprehensive services provided by WPP are intended to allow individuals to live in the setting of their choice. While similar to PACE, WPP does not require that providers operate an adult day center. ALTCS, the long-term care division of the Arizona Medicaid program, serves individuals who are age 65 and over, blind, or disabled and who need ongoing services at a nursing home level of care. Arizona provides all its Medicaid services through a Medicaid waiver, which allows some flexibility in the design and administration of the program. In Arizona, ALTCS contracts with providers to deliver acute medical care services, institutional care, hospice, behavioral health services, home health, homemaker services, personal care, respite care, transportation, adult day care, and home delivered meals. Many ALTCS participants are able to live in their own homes or in assisted living facility and receive in-home services. Palliative care programs are operated by a variety of health care entities, including hospitals, health care systems, and hospices. These programs generally do not receive federal or state funding and may rely on private grants or charitable support. Palliative care programs are designed to improve the quality of a seriously ill individual’s life and support the individual and his or her family during and after treatment. Services provided by palliative care programs vary and may include pain and symptom management, assistance with planning for additional services, and psychosocial and spiritual support and can be provided in conjunction with curative care. The IOM and AHRQ studies identified the following key components in providing care to individuals nearing the end of life: care management; supportive services for individuals; pain and symptom management; family and caregiver support; communication among the individuals, families, and program staff; and assistance with advance care planning. Care management, also referred to as case management, interdisciplinary care, or care coordination, is the coordination and facilitation of service delivery and can be provided by a team or a single manager. Supportive services include personal care services, home delivered meals, transportation to medical appointments, and other services that assist individuals who reside in noninstitutional settings. Pain and symptom management is pharmacological and nonpharmacological therapies, such as massage therapy, to treat pain and other symptoms of an individual who is seriously ill. Family and caregiver support are services that provide assistance to those caring for an individual nearing the end of life in his or her home and can include respite care and bereavement counseling. Communication among individuals, families, and program staff includes discussions regarding end-of-life issues with individuals and their family members and the use of various tools to foster communication among program staff. Advance care planning is the process by which individuals make decisions about their future care and may include the completion of written documents, such as advance directives. Specifically, IOM reported that for individuals nearing the end of life, care systems should ensure that the following are provided: interdisciplinary care management; home care or personal care services, which we refer to as supportive services; pain and symptom management; supportive care for caregivers and family through services such as respite care or housekeeping services; and communication. The IOM report also identified advance care planning as a key component of end-of-life care. The IOM report recommended that people nearing the end of life should receive supportive services managed by those involved in their care and that health care organizations should facilitate advance care planning. In addition, the IOM report recommended that health care professionals improve care for individuals nearing the end of life by providing pain and symptom management. The AHRQ report focused on identifying outcomes that can indicate the quality of the end-of-life experience and identifying the patient, family, and health care system factors that are associated with better or worse outcomes at the end of life. The AHRQ report identified continuity of health care, such as that provided through care management; supportive services, such as home care services; pain and symptom management; support for families and caregivers; and effective communication among program staff, which could include improved medical record documentation, as core components of end-of-life care. The programs we identified in four states that incorporate key components of end-of-life care described in the IOM and AHRQ reports are PACE, WPP, ALTCS, and palliative care programs. These programs use care management to ensure continuity of care and supportive services, such as personal care services, to assist individuals nearing the end of life. These programs also integrate pain and symptom management into their services; provide family and caregiver support; foster communication among the individuals, families, and program staff; and initiate or encourage advance care planning. Care management is used by all of the programs we identified to ensure continuity of care for individuals nearing the end of life. Most of these programs provide care management through interdisciplinary care teams. The interdisciplinary care teams of PACE providers include a primary care physician, nurse, social worker, physical therapist, occupational therapist, recreational therapist or activity coordinator, dietitian, PACE adult day center manager, health care aides, and transportation providers. PACE beneficiaries attend a PACE adult day center where they receive services from the interdisciplinary care team. The WPP providers use an interdisciplinary care team approach similar to PACE, although the teams are generally smaller. Representatives of two WPP providers we interviewed stated that care management reduces hospitalizations. Representatives of one of these providers stated that care management ensures that individuals admitted to a hospital are discharged to an appropriate setting to avoid unnecessary readmission. Representatives of the second WPP provider stated that care management improves the medical care of individuals by providing physicians with an accurate picture of individuals’ health status and assisting individuals with accessing physicians in a timely manner. Representatives of both PACE and WPP providers stated that the interdisciplinary care teams meet to exchange information, ensure that individuals’ needs are being met, and address changes in the health status of individuals. The four hospital-based palliative care programs we identified use interdisciplinary care teams to coordinate services. These programs’ teams include medical directors, social workers, chaplains, nurses, psychologists, and case managers. Two of the hospice-based palliative care programs developed partnerships with local hospitals and use interdisciplinary care teams to assist individuals. Two other hospice-based palliative care programs use interdisciplinary care teams of health care professionals to coordinate medical, nursing, social work, and spiritual services. Staff from one of these programs told us that because case managers facilitate communication among different medical providers and ensure that tests performed have a clear purpose, unnecessary or duplicate tests are avoided. One hospice-based palliative care program’s interdisciplinary care team consists of a nurse, social worker, and palliative care physician who coordinate care and monitor the quality of care provided. The two palliative care programs operated by health care systems use interdisciplinary care teams composed of nurses, social workers, chaplains, and pharmacists. The care team of one of these palliative care programs makes treatment recommendations and enhances coordination among medical staff. The other of these palliative care programs provides social and psychological support and assists individuals with transitioning between the hospital and their homes. One hospice-based palliative care program uses a single case manager to assist individuals with coordinating services. In the ALTCS program, each Medicaid beneficiary is assigned a case manager. The case manager aids the beneficiary in obtaining necessary services, coordinates service delivery, and consults with other providers as needed. ALTCS case managers refer beneficiaries to other social service agencies when additional services are needed. ALTCS officials noted that a unique feature of the program is that it provides institutional, supportive, and all other medical and long-term care services under one agency and under the supervision of a single case manager for each beneficiary. An official also noted that the ALTCS program fosters continuity of care and care coordination at the end of life through the case manager and the integrated delivery of services from a single agency. The programs we identified provide a variety of supportive services to assist individuals near the end of life. The PACE providers we interviewed are required to deliver supportive services such as personal care services, adult day care, social work services, and meal delivery. Representatives of one PACE provider stated that one strength of PACE is the integration of all Medicare- and Medicaid-covered services, which includes the supportive services, such as personal care services, covered by Medicaid. Representatives of a PACE provider reported that when individuals become too frail to come to the day center, a designated team visits individuals in their homes to provide personal care, nursing, and physician services.