Interventions for Frequently Hospitalized Patients and Their Effect on Outcomes: A Systematic Review Mixed evidence for efforts to reduce rehospitalizations. Peer-Reviewed Article 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
Persistence and Drivers of High-Cost Status Among Dual-Eligible Medicare and Medicaid Beneficiaries Analyzes the largest drivers of high costs among persistently high-cost Medicare-Medicaid beneficiaries, and finds most spending related to long-term care. Peer-Reviewed Article October 2018
A New Hospitalist Model for Managing High-Cost, High-Need Patients A hospitalist model for complex care. Case Example October 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
Engaging High-Need Patients in Intensive Outpatient Programs: A Qualitative Synthesis of Engagement Strategies Overcoming barriers to patient engagement. Peer-Reviewed Article August 2018
Permanent Supportive Housing: Evaluating the Evidence for Improving Health Outcomes Among People Experiencing Chronic Homelessness Permanent supportive housing shows mixed results in improving health outcomes and health care costs for people experiencing chronic homelessness. Brief/Report July 2018
Patient Engagement in ACO Practices and Patient-Reported Outcomes Among Adults with Co-Occurring Chronic Disease and Mental Health Conditions Patient engagement improves patient-reported outcomes. Peer-Reviewed Article July 2018
Going Beyond Clinical Care to Reduce Health Care Spending A regional approach to health care transformation. Peer-Reviewed Article July 2018
Systematic Review of High-Cost Patients’ Characteristics and Healthcare Utilisation An international analysis of high-cost patients. Peer-Reviewed Article July 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
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
Medical Respite for People Experiencing Homelessness: Financial Impacts with Alternative Levels of Medicaid Coverage A financial analysis projected that hospitals and health plans could achieve cost savings by investing in medical respite programs. 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
The CHRONIC Care Act of 2018: Advancing Care for Adults with Complex Needs A brief summarizes what you need to know about the new Chronic Care Act. Brief/Report March 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
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
Development of a Care Guidance Index Based on What Matters to Patients The What Matters Index measures quality of life for people with chronic conditions. Peer-Reviewed Article January 2018