Quick Reference Guide to Promising Care Models This resource is an updated quick reference guide to promising models for people with complex needs. Brief/Report February 2019
The ROI Calculator for Partnerships to Address the Social Determinants of Health A web-based financial tool that helps navigate partnerships between health care organizations and social service organizations. Implementation Tool August 2018
Engaging High-Need Patients in Intensive Outpatient Programs: A Qualitative Synthesis of Engagement Strategies Overcoming barriers to patient engagement. Peer-Reviewed Article August 2018
Going Beyond Clinical Care to Reduce Health Care Spending A regional approach to health care transformation. Peer-Reviewed Article July 2018
Medical Respite for People Experiencing Homelessness: Financial Impacts with Alternative Levels of Medicaid Coverage A financial analysis projected that hospitals and health plans could achieve cost savings by investing in medical respite programs. Peer-Reviewed Article May 2018
Meal Delivery Programs Reduce the Use of Costly Health Care in Dually Eligible Medicare and Medicaid Beneficiaries Examines how home meal delivery programs show promise for reducing the use of costly health care and decreasing spending for dually eligible individuals. Peer-Reviewed Article April 2018
Using Community Partnerships to Integrate Health and Social Services for High-Need, High-Cost Patients This brief describes new ways for health care to address social determinants of health. Brief/Report January 2018
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
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