How High-Need Patients Experience Health Care in the United States This 2016 survey reveals that the health care system is failing people with complex needs Brief/Report December 2016
Reduced Emergency Room and Hospital Utilization in Persons with Multiple Chronic Conditions and Disability Receiving Home-Based Primary Care People with multiple chronic conditions and disabilities enrolled in home-based primary care experienced persistent reduced acute care utilization. Peer-Reviewed Article October 2016
New Models of Primary Care Workforce and Financing: Case Example #1: Stanford Coordinated Care Stanford Coordinated Care provides university employees with complex health needs better care at a lower cost Case Example October 2016
Tailoring Complex Care Management, Coordination, and Integration for High-Need, High-Cost Patients Improving care for high-need, high-cost patients is a key lever to decrease national health spending. Brief/Report September 2016
What Matters Most: Essential Attributes of a High-Quality System of Care for Adults with Complex Care Needs Experts describe how delivery systems can effectively serve adults with complex needs. Brief/Report September 2016
Delivery System Reform: Improving Care for Individuals Dually Eligible for Medicare and Medicaid Dual-eligible beneficiaries are often more sick, have greater functional and cognitive impairments, and require more care coordination. Brief/Report September 2016
High-Need, High-Cost Patients: Who Are They and How Do They Use Health Care? There is considerable variation in use and spending among high-need adults, suggesting this population should be segmented into subgroups. Brief/Report August 2016
The Hospital at Home Model: Bringing Hospital-Level Care to the Patient The program offers a lower-cost alternative to the hospital for patients who can be safely treated at home. Case Example August 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
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
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
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
The Health Resilience Program: A Program Assessment Health Resilience Specialists work with the patients to meet their personal health needs Case Example January 2016
Attributes Common to Programs That Successfully Treat High-Need, High-Cost Individuals Targeting is important, even within the high-need patients enrolled in the program. Peer-Reviewed Article November 2015
Models of Care for High-Need, High-Cost Patients: An Evidence Synthesis Much of the evidence comes from small studies, so further testing is needed. Brief/Report October 2015