Next week, I’ll be speaking to faculty and others at the University of Massachusetts School of Medicine on the importance of fully integrating long-term care services and supports with  medical care.  On May 23, I’ll be delivering the same message to a large non-profit health system that includes more than two dozen hospitals.

Physicians and health system adminstrators are beginning to get it: For all the talk about the importance of better integrating health care for those with chronic illness, they are recognizing that appropriate personal care is just as important. No patient with chronic  disease will thrive without a good support system at home or in a nursing facility, no matter how good their medical care.

Imagine, for example, an 80-year old woman with congestive heart failure who falls and fractures her hip ( sadly, an extremely common situation). She goes to the hospital where a skilled surgeon repairs her hip. But now what?  Will she go home for rehab, or to a nursing facility? ONce she does go home. who will be there are care for her? Who will make sure she takes her heart medicine? Will somebody be there to weigh her every day (weight gain is a sure sign that her heart isn’t pumping as efficiently as possible)? Will she still be able to cook for herself and, if she can’t, who will help her?

Not so long ago, many hospitals didn’t even think about these issues. Some still don’t. Discharge planning is often  the broken link in the chain of care, uncompensated by Medicare or private insurance. Overworked social workers with little time and less information struggle to throw together a plan. And once you are rolled out the front door, too many hospitals feel you are no longer their concern. If you can’t manage your medications after you get home, you might be written off as non-compliant (and trust me, you never want to get that label). If things get really bad, you might be readmitted. But, for hospitals with empty beds, that’s not so bad. It just means more money from Medicare.

But now, all that is changing. Top quality hospitals already understand that even in today’s system, they don’t  want their beds filled with pneumonia or heart failure patients. More important, the 2010 health law included a provision that will slash Medicare payments for patients that are readmitted within 30 days of discharge.

That new rule is a big clumsy stick, but it is getting the attention of hosptial administrators. And now, they are beginning to understand that it is in their financial interest, as well as in the best interest of the health of their patients, to help those with chronic disease manage their care after discharge. And a key element of that for many elderly or disabled is the personal assistance often called long-term care.

Making it work will require the cooperation of hospitals, physicians, nursing homes, and home health agencies. Making that work in fee-for-service medicine is very hard. But the health law is making it possible for providers to experiment with new ways to deliver care.

The system has miles to go. Among other things, we’ve got to figure out how we are going to pay for this assistance (Medicare won’t for more than a few months and Medicaid only will if you are very poor and in need of extensive care). But the best thinkers in health systems are working hard to figure it out. They deserve credit for their efforts.