Fixing the Gaps: How Integrated Care is Transforming Healthcare for High-Need Populations in the US and Europe
In today’s healthcare landscape across the U.S. and Europe, systems are under growing pressure. Chronic disease is on the rise, populations are aging, healthcare costs are escalating, and fragmented coverage models continue to create inefficiencies. These challenges not only place financial strain on governments but also severely affect individuals with complex healthcare needs—particularly those dually eligible for Medicare and Medicaid.
This dually eligible population often lives with multiple chronic conditions, such as diabetes, cardiovascular disease, cognitive impairment, and mental health disorders. Many require long-term services and supports, including home care, assisted living, or rehabilitation. However, due to fragmentation in service delivery, patients frequently experience duplicative tests, medication errors, and poor communication across care providers—sometimes with life-threatening consequences.
Consider the case of Margaret, a 76-year-old from Florida. She lives with diabetes, chronic heart failure, and early-stage Alzheimer’s. Relying on more than five prescription medications and regular home care assistance, she navigates care from a primary care physician, mental health counselor, and a home health agency—all of whom operate in silos. The lack of care coordination resulted in three hospitalizations over two months due to adverse drug interactions. Her experience is far from rare. According to data from the Centers for Medicare & Medicaid Services (CMS), there are approximately 12 million dually eligible individuals in the United States, over 60% of whom have three or more chronic conditions. Their annual healthcare expenditures are significantly higher than those of the general population, with elevated emergency department visits and hospitalization rates.
To address these issues, the CMS established a national technical assistance hub: the Integrated Care Resource Center (ICRC). Managed by the health policy research organization Mathematica, the ICRC’s mission is to assist state governments in improving care coordination for dually eligible individuals—especially those who are high-cost and high-need—through evidence-based, person-centered integrated care models.
The ICRC offers a wide range of supports, from one-on-one technical assistance to customized consulting for states at any level of readiness. Whether a state is in the initial planning phase or operating a mature integrated care program, ICRC provides critical guidance on payment model design, contract structuring, regulatory compliance, and stakeholder engagement. Its services also include webinars, policy toolkits, implementation guides, and lessons learned from real-world case studies.
Minnesota is one state that has partnered with ICRC to develop innovative integrated payment models, enabling the blending of funds from Medicare and Medicaid and improving service alignment across health, behavioral, and long-term care. Early results show increased enrollment in coordinated care programs and a marked reduction in avoidable hospitalizations.
Personal stories offer some of the most powerful evidence. In Boston, Massachusetts, a city-wide pilot program supported by ICRC now serves more than 5,000 dually eligible residents through a multidisciplinary care team model. One beneficiary, 72-year-old Gerald, had long struggled with chronic obstructive pulmonary disease (COPD) and severe depression. After years of frequent ER visits and repeat hospitalizations, Gerald enrolled in the integrated program. His care is now managed by a team of physicians, mental health professionals, care coordinators, and nutritionists who share real-time health data and work together on a unified care plan. His hospitalizations dropped by 70%, and he has re-engaged with his community. “I’m no longer just a number,” he says. “I feel like a whole person again.”
This approach is not unique to the United States. Integrated care is gaining traction across Europe as well. In the UK, the National Health Service (NHS) is rolling out Integrated Care Systems (ICS) to unify health and social services, especially for older adults with complex needs. Germany and the Netherlands have also implemented interdisciplinary care models over the past decade, using national payment reforms to encourage data-sharing and coordination across providers.
The evidence is clear: integrated care is not an expensive ideal—it is a practical solution that reduces costs and improves outcomes. In a world where aging populations and chronic disease are the new normal, person-centered integrated care will become an essential pillar of sustainable healthcare policy. Technological advancements like telehealth, AI-driven predictive models, and wearable health trackers are further enhancing the potential of integrated care systems, enabling more proactive, personalized, and efficient service delivery.
Yet technology alone is not enough. Cultural and structural shifts are required. Policymakers must align Medicare and Medicaid funding streams and eliminate administrative barriers. Healthcare organizations must adopt collaborative care models and shared data platforms. Patients and families must be empowered to participate in care planning, and nonprofits must play a role in advocacy and community outreach.
When health systems center their design around people rather than institutions, efficiency, equity, and satisfaction improve. Integrated care represents more than a strategy—it reflects a social and moral responsibility to provide care that is continuous, respectful, and inclusive of every individual’s full spectrum of needs.
Looking ahead, integrated care is set to evolve from a niche policy innovation to a core component of modern healthcare systems in the U.S., Europe, and beyond. As we face a future defined by demographic shifts and escalating demand for complex care, success will depend on our ability to break down silos and build systems that work for everyone—especially those who need it most.
As one ICRC project coordinator aptly said: “Integrated care isn’t just a model. It’s a commitment to treating people as whole human beings. The goal is simple: care that’s compassionate, coordinated, and truly accessible.”