Medicare's integration imperative: A policy analysis of care coordination barriers for older adults with co-occurring mental health and substance use disorders

Abstract

Background

Medicare serves 65 million Americans aged 65+, with 3.7% having co-occurring mental health and substance use disorders. Despite evidence supporting integrated care, fragmented Medicare policies result in higher readmissions and lower treatment completion rates for this vulnerable population.

Purpose

To analyze Medicare policies using the Integration Continuum Framework and identify nursing practice and policy implications for older adults with dual diagnoses.

Methods

Systematic review of Medicare policy documents (2010–2023) analyzed through the Integration Continuum Framework across clinical, financial, and administrative dimensions.

Discussion

Medicare policies predominantly reflect minimal integration (Levels 1–2). Only 17.3% of beneficiaries with co-occurring disorders receive coordinated care, requiring visits to 3.7 providers across 2.8 facilities compared to 1.9 providers at 1.6 facilities for single diagnoses. The Collaborative Care Model achieves Level 3 integration but excludes substance use disorders, limiting comprehensive care.

Conclusion

Medicare's fragmented approach creates significant coordination challenges. Nurses are uniquely positioned to bridge these gaps through screening protocols, care navigation, and leadership initiatives. Policy reforms including expanding the Collaborative Care Model to include substance use disorders, eliminating same-day billing restrictions, and streamlining documentation represent pathways toward comprehensive Level 4–5 integration, ultimately improving outcomes for older adults with dual diagnoses.