An interdisciplinary team approach can improve care coordination and reduce length of hospital stays for older adults with complex health and social needs.
Describes electronic health record system functionality that automatically identifies patients likely to need technical assistance prior to telehealth visits.
Systematic review finds mixed results for health information technology in enhancing coordinated care and improving health outcomes for people with multiple chronic conditions.
Longer participation in a patient-centered medical home is associated with better mental health care for people enrolled in Medicaid with major depressive disorder and multiple chronic conditions.
CAPABLE, a home-based care program that provides interdisciplinary services for older adults, leads to reductions in disability as well as cost savings.
Offers practical recommendations to improve telemedicine interventions to be more equitable for diverse populations, particularly those with low incomes.
Case study of interdisciplinary primary care program for high-risk patients based at an academic health system offers lessons on program design and implementation.
A Comprehensive Medication Management program that employs a remote clinical pharmacist effectively addresses most drug therapy problems in a complex care population.
During the COVID-19 pandemic, Cityblock Health implemented a virtually integrated care management model to maintain continuity of care for patients with complex needs.
Randomized controlled trial of a care management intervention shows significant improvement in patient activation and self-rated health and decreased symptoms of depression in patients with complex needs.
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.