When the COVID-19 pandemic struck, One Community Health partnered with OCHIN to rapidly transform its care delivery model, implementing new virtual care tools to safely and effectively serve vulnerable patients with complex needs through the pandemic and beyond.

Features a conversation with Terry Fulmer, president of the John A. Hartford Foundation, who discusses potential solutions for older adults experiencing social isolation and loneliness — both during and after the COVID-19 pandemic.

Features a conversation with Lori Tishler, senior vice president of medical services at Commonwealth Care Alliance, who shares how CCA is rethinking its day-to-day practice to address the COVID-19 pandemic.

Bruce Chernof, MD, President and CEO of The SCAN Foundation, highlights flexibilities that allow health systems to respond to the growing challenges due to COVID-19.

Features senior leadership from Health Share of Oregon who provide details about their efforts to mitigate issues that will affect their members due to COVID-19.

Describes key opportunities for the continued development of complex care best practices, gleaned from recent randomized controlled trials.

Features a conversation with Miriam Komaromy, MD, former ECHO Care lead, who shared key takeaways from the recent evaluation of the intervention to help inform complex care programs.

Features David Labby, MD, health strategy advisor for Health Share of Oregon, who provides insights on the recently released report on Camden Coalition's randomized controlled trial on the Camden Core Model.

Kedar Mate, MD, Chief Innovation and Education Officer at the Institute for Healthcare Improvement, discusses opportunities to integrate social care into health care delivery, based on a recently released National Academies of Sciences, Engineering, and Medicine report.

Highlights how skilled nursing facilities are switching to the Patient Driven Payment Model — a payment system that removes therapy minutes as the basis for payment and enhances payment accuracy for services by making reimbursement dependent on a wide range of clinical characteristics.

Discusses, COACH, a new framework that Camden Coalition utilizes to build authentic relationships with patients and to increase patient engagement.

Explores the use of asset mapping to build stronger ecosystems of care, address the root causes of repeated hospital utilization, and improve care delivery for individuals with complex health and social needs.

Explores the tension between health systems and community-based organizations and discusses strategies for successfully navigating it.

Explores the Camden Coalition of Healthcare Providers’ Health Information Exchange, a web-based application that gives providers across health systems real-time access to medical information for patients with complex needs.

Our ability to effectively treat the growing number of individuals who live with multiple chronic diseases will remain compromised unless health systems explore innovative approaches.

New flexibility for Medicare Advantage program represents a major turning point in Medicare policy and an opportunity for health insurers and providers to work together in new and more productive ways.

For frail older adults with complex care needs, an inpatient hospital stay is destabilizing and often marks the beginning of a decline in functioning. For these older adults and their families, the post-hospital period is a risky, confusing, and stressful time.

The time constraints of the typical primary care practice often do not allow providers to take a comprehensive look at all of their patients’ needs. Enabling office staff to assist in this work, presents a tremendous opportunity to create patient-centered and comprehensive care plans.

From continued enrollment growth to expanded flexibility to offer non-medical supplemental benefits, Medicare Advantage plans are playing an increasingly important role in the lives of older adults.

Christine Schaeffer, MD, medical director of Northwestern Medicine Transitional Care Clinic, describes the core components of its transitional care program. She also shares important considerations for health systems interested in implementing person-centered transitional care.