Effective Management of High-Risk Medicare Populations A three-pronged strategy can help manage care for Medicare beneficiaries. Brief/Report September 2014
Caring for High-Need, High-Cost Patients: What Makes for a Successful Care Management Program? A comparison of 18 complex care management programs reveals best practices. Brief/Report August 2014
Utilization of Hot Spotting to Identify Community Needs and Coordinate Care for Patients in Memphis, TN The approach identifies patients through chart review and data analytics coupled with the intelligence of community health workers. Peer-Reviewed Article February 2014
Pursuing Financial Sustainability of Person-Centered Care Models Setting up data collection systems is important to showing value. Implementation Tool January 2014
Emergency Department Super-Utilizer Programs: Rural Health Systems Analysis and Technical Assistance Project This guide describes how to design, implement, and assess a program to reduce preventable ED use. Implementation Tool October 2013
Generating Hypotheses about Care Needs of High Utilizers: Lessons from Patient Interviews This resource presents promising ideas for more effective modes of care for persons with complex needs. Peer-Reviewed Article September 2013
Medical Respite Programs for Homeless Patients: A Systematic Review Systematic review finds that medical respite programs reduce acute care utilization outcomes for people experiencing homelessness. Peer-Reviewed Article May 2013
Effect of a Community-Based Nursing Intervention on Mortality in Chronically Ill Older Adults: A Randomized Controlled Trial Indicates that a community-based nurse care management model reduced all-cause mortality for older adults with chronic conditions. Peer-Reviewed Article July 2012
Six Features of Medicare Coordinated Care Demonstration Programs that Cut Hospital Admissions A study showed that some programs reduced hospitalizations by 8 to 33 percent. Peer-Reviewed Article June 2012
Complex Care Management Toolkit Lessons learned from eight health care organizations can help you design a successful program. Implementation Tool April 2012