For the Uninsured in Memphis, a Stronger Safety Net Moving patients out of the ED and into community support. Case Example September 2019
HOUSED BEDS: A Clinical Tool for Taking a History on an Unsheltered Homeless Patient A tool helps providers capture essential information when interviewing people experiencing unsheltered homelessness to support effective treatment planning. Implementation Tool July 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
How ACOs Are Caring for People with Complex Needs An analysis of the National Survey of ACOs Brief/Report December 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
Going Beyond Clinical Care to Reduce Health Care Spending A regional approach to health care transformation. Peer-Reviewed Article July 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
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
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
CareMore: Improving Outcomes and Controlling Health Care Spending for High-Needs Patients CareMore’s business model identifies high-risk patients and surrounds them with coordinated services Case Example March 2017
Innovative Home Visit Models Associated with Reductions in Costs, Hospitalizations, and Emergency Department Use Home visits can reach patients with complex needs before a higher level of care is needed Peer-Reviewed Article March 2017
The Business Case for Community Paramedicine: Lessons from Commonwealth Care Alliance’s Pilot Program Cost considerations for the expansion of mobile integrated health care and community paramedicine programs. Case Example December 2016
Intensive Outpatient Care Program Toolkit The staff position of care coordinator is crucial to success. Implementation Tool December 2016
Care Management Plus: Strengthening Primary Care for Patients with Multiple Chronic Conditions A program to help clinics deliver comprehensive care may decrease mortality and hospitalization rates. Case Example December 2016
Guided Care: A Structured Approach to Providing Comprehensive Primary Care for Complex Patients Guided Care is designed to strike a balance between telephone-based and interdisciplinary team-based care management programs. Case Example October 2016
The Core of Care Management: The Role of Authentic Relationships in Caring for Patients with Frequent Hospitalizations This study links “authentic healing relationships” with patient motivation and active health management. Peer-Reviewed Article August 2016
Developing Care Management Programs to Serve High-Need, High-Cost Populations Care management programs should include processes for evaluating patient-reported outcomes. Brief/Report February 2016
Models of Care for High-Need, High-Cost Patients: An Evidence Synthesis Much of the evidence comes from small studies, so further testing is needed. Brief/Report October 2015
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
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