The Guide to Integrating Palliative Care into Population Management Practical strategies for health plans and ACOs to improve care for patients with serious illness. Implementation Tool February 2019
High-Need, High-Cost Personas An in-depth overview of different personas. Implementation Tool February 2019
The Opioid Use Disorder Prevention Playbook Strategies for preventing opioid use disorder. Implementation Tool February 2019
Re-envisioning Care for People with Involved Disabilities Video series details how health systems can redesign primary care, including through home-based primary care programs, to better meet the needs of people with disabilities. Implementation Tool February 2019
Designing and Implementing Home-Based Palliative Care: A Guide for Payers A practical guide for payers to create a home-based palliative care program centered upon a value-based case example from a payer’s perspective. Implementation Tool January 2019
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
The ROI Calculator for Partnerships to Address the Social Determinants of Health A web-based financial tool that helps navigate partnerships between health care organizations and social service organizations. Implementation Tool August 2018
Care Management Contracting for Complex Populations: Best Practices and Tools This resource offers guidance on contracting for populations with complex needs. Implementation Tool July 2018
Investing in Social Services as a Core Strategy for Healthcare Organizations: Developing the Business Case This resource explains how to invest in social services as a business strategy. Implementation Tool 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
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