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.
Provides practical steps for current or potential future Medicare accountable care organizations to transform the delivery of care, including through telehealth, home visits, and skilled nursing care.
Home-based primary care programs made rapid care delivery adaptations in response to the COVID-19 pandemic, and this flexibility may support new opportunities to care for older, medically complex patients safely in their homes.
Includes promising practices, recommendations, vignettes, and other helpful tools to assist health systems in supporting family caregivers providing complex care.
Describes core competencies that convey the essential knowledge, skills, and attitudes of complex care practitioners and teams to improve care for people with complex needs.
Details funding opportunities and successful approaches in the adoption of evidence-based health promotion and disease prevention programs within community-based organizations.
Identifies opportunities to strengthen integrated programs to improve care and support positive health outcomes for dually eligible individuals both during and beyond the pandemic.
Offers a practical framework for safety-net health systems to better identify and segment patients with complex needs, and tailor care models to meet their needs.
Growth in Medicare Advantage plans linked to decreased cost and utilization for high-need, high-cost fee-for-service Medicare beneficiaries with multiple chronic conditions.