During the COVID-19 pandemic, Cityblock Health implemented a virtually integrated care management model to maintain continuity of care for patients with complex needs.
Personalized patient navigation supports for people with comorbid substance use disorders reduced rates of hospital readmissions and emergency department use.
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.
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.
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.
Enhanced primary care for adults with serious mental illness led to increases in primary care visits and health screenings as well as decreases in inpatient utilization.
Initiative successfully implemented several evidence-based and promising addiction care models across multiple medical settings, including an inpatient addiction consult team, a low-threshold bridge clinic, peer recovery coaches, and office-based addiction treatment nurses.
Demonstrates that intensive outpatient care programs show promise in reducing utilization and costs and improving patient outcomes for high-need, high-cost populations.