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.
This case study highlights an accountable care organization’s home-based primary care program for homebound older adults, with early analysis of outcomes showing reduced acute care utilization.
Among high-cost Medicare enrollees, those who are seriously ill, frail, and/or had a serious mental illness experience the most potentially preventable spending.
Providing virtual case mentoring to outpatient care teams may reduce unnecessary hospital and emergency department visits for high-need, high-cost patients.
Contains strategies, tips, and case studies to assist health care stakeholders in building meaningful, person-centered engagement in their organizations.
A unique cross-sector partnership involving health care, police, and emergency services improved health care utilization in this rural health system pilot.
When identifying patients with complex health needs for interventions, algorithms that rely on cost data as a proxy for health status may lead to under-identification of Black patients.