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.
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.
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.
Demonstrates that intensive outpatient care programs show promise in reducing utilization and costs and improving patient outcomes for high-need, high-cost populations.
Complex care management program within Next Generation Accountable Care Organizations reduced cost and utilization for high-risk Medicare beneficiaries.
Integrated health care systems can better support high-risk patients by embedding high-risk patient care within general primary care and mental health care.