Using segmentation to address clinical and social needs for Medicaid patients with complex needs and costly utilization can improve the effectiveness of complex care programs.
Trust, flexible funding, cross-sector support, sustainability, and an explicit focus on structural racism are identified as key components of effective community engagement to advance health equity.
Offers practical recommendations to improve telemedicine interventions to be more equitable for diverse populations, particularly those with low incomes.
Use of hospital readmission rates to measure quality may be unfair for some accountable care organizations and safety-net providers, since members with complex medical and social needs are a main driver of these rates.
Primary care and alternative payment models that reduce emergency department use and increase access to care for high-need populations share core components for success.
Use of machine learning clustering algorithms revealed 30 distinct subgroups of patients among high-risk veterans, indicating a need for tailored approaches to health care.
Discusses the benefits and challenges of tele-social care and offers practical tips for providers administering telehealth services for social care activities.
Suggests that community-based organizations are responding to Medicaid redesign efforts that prioritize social determinants of health by adopting practices similar to health care organizations.
Describes core competencies that convey the essential knowledge, skills, and attitudes of complex care practitioners and teams to improve care for people with complex needs.
Offers a practical framework for safety-net health systems to better identify and segment patients with complex needs, and tailor care models to meet their needs.