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
Improving Population Health Management Strategies: Identifying Likely Users of Avoidable Costly Care Assessing patients’ activation levels can help identify those at risk for poor health outcomes and utilization of avoidable, costly care. Peer-Reviewed Article August 2016
The Core of Care Management: The Role of Authentic Relationships in Caring for Patients with Frequent Hospitalizations This study links “authentic healing relationships” with patient motivation and active health management. Peer-Reviewed Article August 2016
Health System Performance for the High-Need Patient: A Look at Access to Care and Patient Care Experiences One in five high-need adults reported having an unmet medical need. Brief/Report August 2016
Project ECHO’s Complex Care Initiative: Building Capacity to Help “Superutilizers” Interdisciplinary teams provide support for Medicaid beneficiaries with mental illnesses, addictions, and other needs. Case Example August 2016
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
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
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