Health Care Hotspotting — A Randomized, Controlled Trial Randomized controlled trial of a care management intervention offers important lessons for the field of complex care. Peer-Reviewed Article January 2020
The Common Attributes of Successful Care Manager Programs for High-Need, High-Cost Persons: A Cross-Case Analysis Ten common attributes for successful care management programs serving high-need, high-cost populations. Peer-Reviewed Article October 2019
For the Uninsured in Memphis, a Stronger Safety Net Moving patients out of the ED and into community support. Case Example September 2019
HOUSED BEDS: A Clinical Tool for Taking a History on an Unsheltered Homeless Patient A tool helps providers capture essential information when interviewing people experiencing unsheltered homelessness to support effective treatment planning. Implementation Tool July 2019
‘Eyes in The Home’: ACOs Use Home Visits to Improve Care Management, Identify Needs, And Reduce Hospital Use How home visits are used by ACOs to improve care, lower costs. Peer-Reviewed Article June 2019
Time and Effort in Care Coordination for Patients with Complex Health and Social Needs: Lessons From a Community-Based Intervention Staff time effort in complex care coordination programs is highly variable depending on patients’ health and social needs. Peer-Reviewed Article June 2019
Identifying and Designing the Right Care Management Program: Insights from ACOs Four care management models for ACOs. Implementation Tool April 2019
How ACOs Are Caring for People with Complex Needs An analysis of the National Survey of ACOs Brief/Report December 2018
Outpatient Complex Case Management: Health System-Tailored Risk Stratification Taxonomy to Identify High-Cost, High-Need Patients Maximizing the impact of outpatient complex case management. Peer-Reviewed Article November 2018
Going Beyond Clinical Care to Reduce Health Care Spending A regional approach to health care transformation. Peer-Reviewed Article July 2018
Active Redesign of a Medicaid Care Management Strategy for Greater Return on Investment: Predicting Impactability This resource describes one tool to identify patients most likely to benefit from care management. Peer-Reviewed Article April 2018
Managing Effectively in Complex Chronic Care Markets This resource provides a road map for health plans to improve Medical Loss Ratio. Peer-Reviewed Article February 2018
Community Health Worker Support for Disadvantaged Patients with Multiple Chronic Diseases: A Randomized Clinical Trial This resource describes the benefits of community health workers for people with multiple chronic conditions. Peer-Reviewed Article October 2017
Integrating Health Care for High-Need Medicaid Beneficiaries With Serious Mental Illness and Chronic Physical Health Conditions at Managed Care, Provider, and Consumer Levels This resource describes the value of navigators for Medicaid beneficiaries with mental illness. 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
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
Innovative Home Visit Models Associated with Reductions in Costs, Hospitalizations, and Emergency Department Use Home visits can reach patients with complex needs before a higher level of care is needed Peer-Reviewed Article March 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
Intensive Outpatient Care Program Toolkit The staff position of care coordinator is crucial to success. Implementation Tool December 2016