Improving Care Coordination for Immigrant and Limited-English-Proficient Seniors

A Community-Based Framework Aligned with Medicaid and HCBS Policy Priorities

Author: AgeX Health Foundation

Publication Type: White Paper

Policy Domains: Medicaid, Home- and Community-Based Services (HCBS), Health Equity

Year: 2025

Abstract

Immigrant and limited-English-proficient older adults face persistent barriers in accessing long-term services and supports (LTSS), including fragmented care coordination, language discordance, and limited navigation support across health and social service systems. These barriers contribute to delayed service utilization, avoidable hospitalizations, and premature institutionalization.

This white paper examines structural gaps in current care coordination approaches and proposes a nonprofit-led, community-based framework aligned with U.S. Medicaid and Home- and Community-Based Services (HCBS) policy priorities. The framework emphasizes person-centered assessment, culturally and linguistically responsive engagement, cross-sector coordination, and caregiver support as cost-effective strategies to improve equity and continuity of care.

Policy Context

Federal initiatives led by the Centers for Medicare & Medicaid Services (CMS), the U.S. Department of Health and Human Services (HHS), and the Administration for Community Living (ACL) prioritize HCBS expansion, health equity, caregiver support, and integrated care coordination. This publication translates these national policy goals into a practical, community-level model applicable to diverse aging populations.

While informed by California’s long-term care environment, the challenges and strategies discussed are broadly relevant to states serving aging immigrant communities through Medicaid-funded LTSS programs.

Key Topics

• Care coordination for immigrant and limited-English-proficient seniors

• Medicaid and HCBS access

• Community-based nonprofit service models

• Health equity and caregiver support

• Reduction of avoidable institutionalization

AXH_White_Paper_ADHC_CBAS_Access_Challenges_LA_County.pdf

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About AgeX Health Foundation

AgeX Health Foundation is a nonprofit organization focused on advancing equitable access to aging and long-term care services through research, policy-aligned frameworks, and community-based coordination strategies.

Disclaimer

This publication is for research and informational purposes only and does not constitute legal, medical, or benefits advice.