Offers a practical framework for safety-net health systems to better identify and segment patients with complex needs, and tailor care models to meet their needs.
Toolkit offers health care stakeholders in rural areas with practical information to support the design, implementation, and evaluation of community paramedicine programs.
Examines promising strategies to meet the needs of dually eligible individuals with serious mental illness, with an emphasis on opportunities to innovate with flexible spending within a capitated payment model.
Health care systems may need to tailor screening and referral approaches for social needs, as some needs may be less likely to be met by social service organizations.
Accountable care organizations must address key funding, community partnership, and data sharing requirements to successfully integrate social services into medical care.
Among high-cost Medicare enrollees, those who are seriously ill, frail, and/or had a serious mental illness experience the most potentially preventable spending.
Providing virtual case mentoring to outpatient care teams may reduce unnecessary hospital and emergency department visits for high-need, high-cost patients.