A Practical Guide to Expanding Home-Based Primary Care with Telehealth Tools, tips, and vignettes for incorporating telehealth into home-based primary care models. Implementation Tool December 2019
A Turning Point in Medicare Policy: Guiding Principles for New Flexibility Under Special Supplemental Benefits for the Chronically Ill How to implement the new Medicare benefits. Implementation Tool July 2019
Home-Based Primary Care Resources: A Toolkit for Health Partners This toolkit details the benefits of home-based primary care to help providers demonstrate the need for these programs. Implementation Tool June 2019
Home-Based Primary Care Fall Prevention and Management Toolkit Shares best practices and screening tool options to identify and care for home-based primary care patients with potential fall risks. Implementation Tool April 2019
Identifying and Designing the Right Care Management Program: Insights from ACOs Four care management models for ACOs. Implementation Tool April 2019
State Pathways to Integrated Care: Exploring Options for Medicare-Medicaid Integration Outlines steps states can take to advance Medicare-Medicaid integration depending on policy goals, internal capacity, and delivery system structures. Implementation Tool April 2019
Health Care Transformation Task Force Value Partnership Evaluation Tool A tool for assessing readiness for value-based partnerships. Implementation Tool March 2019
High-Need, High-Cost Personas An in-depth overview of different personas. Implementation Tool February 2019
Blueprint for Complex Care: Advancing the Field of Care for Individuals with Complex Health and Social Needs This resource outlines the current state of complex care and recommendations for the future. Implementation Tool December 2018
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
Care Management Contracting for Complex Populations: Best Practices and Tools This resource offers guidance on contracting for populations with complex needs. Implementation Tool July 2018
Investing in Social Services as a Core Strategy for Healthcare Organizations: Developing the Business Case This resource explains how to invest in social services as a business strategy. Implementation Tool March 2018
Accountable Care Atlas: A Development Guide for Competency Implementation This resources describes the competencies organizations need to transition to value-based payment. Implementation Tool November 2017
Building Complex Care Programs: A Road Map for States This guide for state leaders offers lessons about state-level approaches to complex care. Implementation Tool October 2017
Intensive Outpatient Care Program Toolkit The staff position of care coordinator is crucial to success. Implementation Tool December 2016
The Care Transitions Intervention The Care Transitions Intervention was co-designed with patients and evaluated using randomized trials. Implementation Tool November 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
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
Pursuing Financial Sustainability of Person-Centered Care Models Setting up data collection systems is important to showing value. Implementation Tool January 2014