Impact of Primary Care Intensive Management on High-Risk Veterans’ Costs and Utilization Supplementing primary care with team-based management. 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
Impact of Supportive Housing on Substance Use-Related Health Care Utilization Among Homeless Persons who are Active Substance Users Supportive housing placement for people with substance use disorder (SUD) who are homeless reduces SUD-related health care utilization. Peer-Reviewed Article April 2019
Tools to Support Hospital-Based Addiction Care: Core Components, Values, and Activities of the Improving Addiction Care Team Details the main elements of a hospital-based addiction care consultation team. Case Example March 2019
Quick Reference Guide to Promising Care Models This resource is an updated quick reference guide to promising models for people with complex needs. Brief/Report February 2019
Outcomes of a Citywide Campaign to Reduce Medicaid Hospital Readmissions with Connection to Primary Care Within 7 Days of Hospital Discharge The importance of timely primary care follow-up. Peer-Reviewed Article January 2019
The Current State of Telehealth Evidence: A Rapid Review Telehealth interventions had similar outcomes to in-person care for different services and populations, but did not consistently impact utilization such as physician or emergency department visits. Peer-Reviewed Article December 2018
Blueprint for Complex Care: Advancing the Field of Care for Individuals with Complex Health and Social Needs This resource outlines the current state of complex care and recommendations for the future. Implementation Tool December 2018
How ACOs Are Caring for People with Complex Needs An analysis of the National Survey of ACOs Brief/Report December 2018
Academic Medical Centers and High-Need, High-Cost Patients: A Call to Action This resource describes how academic medical centers can reshape the health system for patients with complex needs. Peer-Reviewed Article November 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
A New Hospitalist Model for Managing High-Cost, High-Need Patients A hospitalist model for complex care. Case Example October 2018
Going Beyond Clinical Care to Reduce Health Care Spending A regional approach to health care transformation. Peer-Reviewed Article July 2018
Case Management in Primary Care for Frequent Users of Health Care Services: A Mixed Methods Study The psychological benefits of case management. Peer-Reviewed Article May 2018
Impact of a Complex Chronic Care Patient Case Conference on Quality and Utilization The case conference approach to caring for complex patients. Peer-Reviewed Article May 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
Complex Care Models to Achieve Accountable Care Readiness: Lessons from Two Community Hospitals Case studies of two community hospitals show how to advance accountable care. Case Example March 2018
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
Effective Care for High-Need Patients: Opportunities for Improving Value, Outcomes and Health The National Academy of Medicine offers a synthesis of the evidence for improving care for high-needs patients. Brief/Report June 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