During the COVID-19 pandemic, Cityblock Health implemented a virtually integrated care management model to maintain continuity of care for patients with complex needs.
Profile of a geriatric emergency department model for older adults with complex needs includes sample policies and workflows as well as recommendations to support effective implementation.
Primary care and alternative payment models that reduce emergency department use and increase access to care for high-need populations share core components for success.
Disparities in transitional care training for caregivers of older adults based on race or financial status demonstrate need for changes in discharge processes and strategies to address bias.
Home-based program provided by a community health and social worker reduces acute care use and improves care for older adults with complex health and social needs.
Toolkit details how hospitals and health systems can use patient race, ethnicity, and language data to advance health equity and eliminate disparities.
Home-based intensive care model for Medicaid and dually eligible enrollees with complex needs led to positive health outcomes and reduced acute care spending, particularly for individuals with a behavioral health diagnosis.
The 4Ms approach developed for the Age-Friendly Health System model — what matters, medication, mentation, mobility — has a robust evidence base for providing quality care to older adults.
Discusses the benefits and challenges of tele-social care and offers practical tips for providers administering telehealth services for social care activities.
Home-based primary care programs enable care teams to gain insights on a variety of social factors that impact older adults’ health, which allows them to better tailor care to meet patient needs.
Home-based primary care programs made rapid care delivery adaptations in response to the COVID-19 pandemic, and this flexibility may support new opportunities to care for older, medically complex patients safely in their homes.