Hennepin Health: A Care Delivery Paradigm for New Medicaid Beneficiaries By closing gaps in care, a safety-net ACO has reduced medical costs for Medicaid patients with complex needs. Case Example October 2016
Home-Based Care Program Reduces Disability and Promotes Aging in Place Difficulty with activities of daily living is a major cost driver in health care that is typically overlooked. Peer-Reviewed Article September 2016
Bridging the Silos of Service Delivery for High-Need, High-Cost Individuals A study of five programs identified key factors that support collaboration among community-based health and social services. Peer-Reviewed Article March 2016
Developing Care Management Programs to Serve High-Need, High-Cost Populations Care management programs should include processes for evaluating patient-reported outcomes. Brief/Report February 2016
Overview of Segmentation of High-Need, High-Cost Patient Population There are many promising strategies to segment individuals with complex needs. Here is one conceptual framework. Implementation Tool January 2016
Targeting Socially Isolated Older Adults: A Process Evaluation of the Senior Centre Without Walls Social and Educational Program A telephone-based virtual senior center may help minimize social isolation and loneliness for older adults. Peer-Reviewed Article December 2015
Supporting a Culture of Health: Opportunities to Improve Models of Care for People with Complex Needs Key opportunities include strengthening information technology connections across service providers. Brief/Report September 2015
Utilization of Hot Spotting to Identify Community Needs and Coordinate Care for Patients in Memphis, TN The approach identifies patients through chart review and data analytics coupled with the intelligence of community health workers. Peer-Reviewed Article February 2014
Medical Respite Programs for Homeless Patients: A Systematic Review Systematic review finds that medical respite programs reduce acute care utilization outcomes for people experiencing homelessness. Peer-Reviewed Article May 2013
Six Features of Medicare Coordinated Care Demonstration Programs that Cut Hospital Admissions A study showed that some programs reduced hospitalizations by 8 to 33 percent. Peer-Reviewed Article June 2012