Leveraging the Social Determinants of Health: What Works? This literature review assesses the impact of social service interventions. Peer-Reviewed Article August 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
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