A New Hospitalist Model for Managing High-Cost, High-Need Patients A hospitalist model for complex care. Case Example October 2018
Impact of a Complex Chronic Care Patient Case Conference on Quality and Utilization The case conference approach to caring for complex patients. Peer-Reviewed Article May 2018
Community Health Worker Support for Disadvantaged Patients with Multiple Chronic Diseases: A Randomized Clinical Trial This resource describes the benefits of community health workers for people with multiple chronic conditions. Peer-Reviewed Article October 2017
Compendium of Five Case Studies: Lessons for Interprofessional Teamwork The VA shares lessons on workforce learning and development. Brief/Report September 2017
Case Managers for High-Risk, High-Cost Patients as Agents and Street-Level Bureaucrats How to improve the cost benefits of case management. Peer-Reviewed Article August 2017
Diffusion of Community Health Workers Within Medicaid Managed Care: A Strategy to Address Social Determinants of Health New Mexico’s model to deploy community health workers is now replicated in 12 states. Case Example July 2017
Innovative Home Visit Models Associated with Reductions in Costs, Hospitalizations, and Emergency Department Use Home visits can reach patients with complex needs before a higher level of care is needed Peer-Reviewed Article March 2017
Nursing Student Coaches for Emergency Department Super Utilizers Nursing students successfully coach patients with complex needs to avoid ED use. Peer-Reviewed Article January 2017
Effect of a Home-Based Palliative Care Program on Healthcare Use and Costs A home-based palliative care program using an interdisciplinary care team reduces hospital costs and unnecessary health care utilization for Medicare Advantage beneficiaries. Peer-Reviewed Article November 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
Bringing Primary Care Home: The Medical House Call Program at MedStar Washington Hospital Center A home-based primary care program decreases costs and utilization for high-risk Medicare enrollees in Washington D.C. Case Example July 2016
Community Care Teams: An Overview of State Approaches The composition of teams varies depending on state staffing requirements and community resources. Brief/Report March 2016
Multiple Chronic Conditions: A Framework for Education and Training A framework describes how to train the health care workforce to care for people with multiple chronic conditions. Implementation Tool June 2015
Effect of a Community-Based Nursing Intervention on Mortality in Chronically Ill Older Adults: A Randomized Controlled Trial Indicates that a community-based nurse care management model reduced all-cause mortality for older adults with chronic conditions. Peer-Reviewed Article July 2012