Person-Centered Care: The Business Case Federal policy changes have made PCC models of care more financially viable. Brief/Report June 2016
Payment to Promote Sustainability of Care Management Models for High-Need, High-Cost Patients Provider incentives must be based on Triple Aim outcomes. Brief/Report May 2016
Taxonomy of Long-Term Services and Supports Integration A standardized tool to assess where along a continuum a program lies with regard to components of integration. Implementation Tool April 2016
Characteristics of Hospital and Emergency Care Super-Utilizers with Multiple Chronic Conditions Patients with a history of high health care utilization may be a good target for a care transition intervention Peer-Reviewed Article April 2016
Key Components for Successful LTSS Integration: Lessons from Five Exemplar Plans Successful long-term services and supports programs have a single point of accountability, such as a care manager. Brief/Report April 2016
Key Ingredients for Successful Trauma-Informed Care Implementation Trauma-informed care can improve patient engagement and treatment adherence while reducing costs. Brief/Report April 2016
So Many Options, Where Do We Start? An Overview of the Care Transitions Literature A systemic review of transitional care interventions reporting hospital readmission Peer-Reviewed Article March 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
Adding a Measure of Self-Management Capability to Risk Assessment Can Improve Prediction of High Costs Less “activated” patients are more likely to benefit from care coordination. Peer-Reviewed Article March 2016
Interventions for Patients with Multimorbidity in Primary Care and Community Settings A review of the evidence suggests it's difficult to improve outcomes for people with multimorbidity. Peer-Reviewed Article March 2016
Evidence on the Green House Model of Nursing Home Care: Synthesis of Findings and Implications for Policy, Practice, and Research A large study on the Green House nursing home model finds promising evidence for improved quality of care and offers implementation recommendations. Peer-Reviewed Article February 2016
Home-Based Primary Care Interventions Systematic review demonstrates the potential of home-based primary care interventions for improving heath, cost, and patient experience outcomes for adults with multiple chronic conditions and serious disabilities. Peer-Reviewed Article February 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
How High-Need Patients Experience the Health Care System in Nine Countries The U.S. had the highest rate of cost-related access problems. Brief/Report January 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
House Calls: California Program For Homebound Patients Reduces Monthly Spending, Delivers Meaningful Care A novel approach to home visiting delivers cost reduction and better care Peer-Reviewed Article January 2016
The Health Resilience Program: A Program Assessment Health Resilience Specialists work with the patients to meet their personal health needs Case Example January 2016
Restoring Dignity for Vulnerable Populations: Changing the System for Complex Patients The benefits of holistic, team-based care go beyond medical needs. Case Example 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
High-Intensity Telemedicine Decreases Emergency Department Use for Ambulatory Care Sensitive Conditions by Older Adult Senior Living Community Residents Telemedicine may expand access to acute illness care and reduce emergency department visits for older adults. Peer-Reviewed Article December 2015