Care Management for Older Adults: The Roles of Nurses, Social Workers, and Physicians How staff composition affects care delivery for older adults. Peer-Reviewed Article June 2019
Impact of Physicians, Nurse Practitioners, and Physician Assistants on Utilization and Costs for Complex Patients Nurse practitioners and physician assistants are associated with lower costs. Peer-Reviewed Article June 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
Tools to Support Hospital-Based Addiction Care: Core Components, Values, and Activities of the Improving Addiction Care Team Details the main elements of a hospital-based addiction care consultation team. Case Example March 2019
Dedicated to the Mission: Strategies US Department of Veterans Affairs Home-Based Primary Care Teams Apply to Keep Veterans at Home Fostering a culture of caring for veterans takes interdisciplinary teams focused on comprehensive, trusting and reliable relationships through open and frequent communication and ongoing education. Peer-Reviewed Article January 2019
A New Hospitalist Model for Managing High-Cost, High-Need Patients A hospitalist model for complex care. Case Example October 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
Define the Care Management Team Outlines how to develop a care team that can help control costs by allowing medical providers to work to the top of their license. Play November 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
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
New Models of Primary Care Workforce and Financing: Case Example #1: Stanford Coordinated Care Stanford Coordinated Care provides university employees with complex health needs better care at a lower cost Case Example October 2016
Project ECHO’s Complex Care Initiative: Building Capacity to Help “Superutilizers” Interdisciplinary teams provide support for Medicaid beneficiaries with mental illnesses, addictions, and other needs. Case Example August 2016
Bringing Primary Care Home: The Medical House Call Program at MedStar Washington Hospital Center A home-based primary care program decreases costs and utilization for high-risk Medicare enrollees in Washington D.C. Case Example July 2016
Community Care Teams: An Overview of State Approaches The composition of teams varies depending on state staffing requirements and community resources. Brief/Report March 2016
House Calls: California Program For Homebound Patients Reduces Monthly Spending, Delivers Meaningful Care A novel approach to home visiting delivers cost reduction and better care Peer-Reviewed Article January 2016
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