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
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
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
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
Proactively Identifying the High-Cost Population Segmenting the high-cost population is the first step in matching appropriate care management strategies. Brief/Report July 2015