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
Disability-Competent Care Self-Assessment Tool How disability-competent is your organization? Implementation Tool October 2017
Designing a Health Care System for Patients with Complex Needs: Ten Recommendations for Policymakers An international expert group offers ten policy recommendations and profiles of innovative care models. Brief/Report September 2017
Compendium of Five Case Studies: Lessons for Interprofessional Teamwork The VA shares lessons on workforce learning and development. Brief/Report September 2017
Case Managers for High-Risk, High-Cost Patients as Agents and Street-Level Bureaucrats How to improve the cost benefits of case management. Peer-Reviewed Article August 2017
High-Cost Dual Eligibles' Service Use Demonstrates the Need for Supportive and Palliative Models of Care Describes the needs of distinct subpopulations within the dually eligible population with highly complex needs, along with opportunities for tailored interventions that may reduce health care spending. Peer-Reviewed Article July 2017
Diffusion of Community Health Workers Within Medicaid Managed Care: A Strategy to Address Social Determinants of Health New Mexico’s model to deploy community health workers is now replicated in 12 states. Case Example July 2017
Effective Care for High-Need Patients: Opportunities for Improving Value, Outcomes and Health The National Academy of Medicine offers a synthesis of the evidence for improving care for high-needs patients. Brief/Report June 2017
Competing Health Care Systems and Complex Patients: An Inter-Professional Collaboration This paper describes competing health care systems can collaborate to improve care for overlapping patient populations. Peer-Reviewed Article June 2017
Bending the Spending Curve: The Role of Care Management in a Pioneer ACO ACOs have lowered costs for high-need patients through care management programs focused on modifiable spending. Peer-Reviewed Article May 2017
State Strategies: Value-Based Payment for Medicaid Populations with Complex Care Needs This brief describes Medicaid payment reform strategies for long-term services and support. Brief/Report April 2017
Preventing Hospitalization with Veterans Affairs Home-Based Primary Care: Which Individuals Benefit Most? Home-based primary care program reduced hospitalizations for older adults with diabetes, especially those with higher levels of medical complexity. Peer-Reviewed Article March 2017
CareMore: Improving Outcomes and Controlling Health Care Spending for High-Needs Patients CareMore’s business model identifies high-risk patients and surrounds them with coordinated services Case Example March 2017
Complex Care Program Development: A New Framework for Design and Evaluation A new framework outlines four steps to develop care management programs. Brief/Report March 2017
Medicaid Managed Care Best Practices Compendium This resource collects the most innovative initiatives in Medicaid managed care that emerge each year. Brief/Report January 2017
Nursing Student Coaches for Emergency Department Super Utilizers Nursing students successfully coach patients with complex needs to avoid ED use. Peer-Reviewed Article January 2017
The Business Case for Community Paramedicine: Lessons from Commonwealth Care Alliance’s Pilot Program Cost considerations for the expansion of mobile integrated health care and community paramedicine programs. Case Example December 2016
How High-Need Patients Experience Health Care in the United States This 2016 survey reveals that the health care system is failing people with complex needs Brief/Report December 2016
Reduced Emergency Room and Hospital Utilization in Persons with Multiple Chronic Conditions and Disability Receiving Home-Based Primary Care People with multiple chronic conditions and disabilities enrolled in home-based primary care experienced persistent reduced acute care utilization. Peer-Reviewed Article October 2016