Care Ecosystem Toolkit Details implementation guidance for the evidence-based Care Ecosystem model, which improves supports for people with dementia and their caregivers. Implementation Tool February 2018
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
Serious Illness Conversation Guide This conversation guide includes specific steps and language for talking about serious illness. Implementation Tool July 2017
Peer Support Toolkit Details the key considerations for providers considering integrating peer services for behavioral health into their health care organizations. Implementation Tool March 2017
Intensive Outpatient Care Program Toolkit The staff position of care coordinator is crucial to success. Implementation Tool December 2016
The Care Transitions Intervention The Care Transitions Intervention was co-designed with patients and evaluated using randomized trials. Implementation Tool November 2016
The Return on Investment (ROI) Calculator: The Business Case and Person-Centered Care A calculator that can help build and present business case for serving adults with complex needs. Implementation Tool November 2016
Taxonomy of Long-Term Services and Supports Integration A standardized tool to assess where along a continuum a program lies with regard to components of integration. Implementation Tool April 2016
Overview of Segmentation of High-Need, High-Cost Patient Population There are many promising strategies to segment individuals with complex needs. Here is one conceptual framework. Implementation Tool January 2016
Multiple Chronic Conditions: A Framework for Education and Training A framework describes how to train the health care workforce to care for people with multiple chronic conditions. Implementation Tool June 2015
Strategies for Hiring and Training Care Managers in Integrated Programs Serving Medicare-Medicaid Beneficiaries Describes practical health plan strategies for hiring and training care managers for dual eligible enrollees with complex needs. Implementation Tool February 2015
Improving Care for People with Serious Illness Through Innovative Payer-Provider Partnerships The benefits of, incentives for, and various models to deliver palliative care are described. Implementation Tool January 2014
Pursuing Financial Sustainability of Person-Centered Care Models Setting up data collection systems is important to showing value. Implementation Tool January 2014
Emergency Department Super-Utilizer Programs: Rural Health Systems Analysis and Technical Assistance Project This guide describes how to design, implement, and assess a program to reduce preventable ED use. Implementation Tool October 2013
Complex Care Management Toolkit Lessons learned from eight health care organizations can help you design a successful program. Implementation Tool April 2012