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
Operation and Challenges of Home-Based Medical Practices in the US: Findings from Six Aggregated Case Studies Strategies for home-based primary care practices to improve efficiency and support program growth based on qualitative research. Peer-Reviewed Article January 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
The Case for Hospital Palliative Care Palliative care is appropriate at any stage of illness and can be provided alongside curative treatment. Brief/Report January 2018
Using Community Partnerships to Integrate Health and Social Services for High-Need, High-Cost Patients This brief describes new ways for health care to address social determinants of health. Brief/Report January 2018
Laying the Groundwork for Trauma-Informed Care How organizations can transition to trauma-informed care. Brief/Report January 2018
A Review of the Essential Components of Quality Palliative Care in the Home Synthesis of studies on effective home-based palliative care emphasizes essential elements for creating a quality program. Peer-Reviewed Article December 2017
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
What Works in Integrated Care Programs for Older Adults with Complex Needs? A Realist Review A literature review describes the most important success factors for integrated care programs. Peer-Reviewed Article October 2017
Community Health Worker Support for Disadvantaged Patients with Multiple Chronic Diseases: A Randomized Clinical Trial This resource describes the benefits of community health workers for people with multiple chronic conditions. Peer-Reviewed Article October 2017
Disability-Competent Care Self-Assessment Tool How disability-competent is your organization? Implementation Tool October 2017
Compendium of Five Case Studies: Lessons for Interprofessional Teamwork The VA shares lessons on workforce learning and development. Brief/Report September 2017
Case Managers for High-Risk, High-Cost Patients as Agents and Street-Level Bureaucrats How to improve the cost benefits of case management. Peer-Reviewed Article August 2017
Toward a Serious Illness Program Design and Implementation Framework This framework can help you design programs for patients with serious illnesses. Peer-Reviewed Article August 2017
Serious Illness Conversation Guide This conversation guide includes specific steps and language for talking about serious illness. Implementation Tool July 2017
High-Cost Dual Eligibles' Service Use Demonstrates the Need for Supportive and Palliative Models of Care Describes the needs of distinct subpopulations within the dually eligible population with highly complex needs, along with opportunities for tailored interventions that may reduce health care spending. Peer-Reviewed Article July 2017
Diffusion of Community Health Workers Within Medicaid Managed Care: A Strategy to Address Social Determinants of Health New Mexico’s model to deploy community health workers is now replicated in 12 states. Case Example July 2017
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