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
Managing Effectively in Complex Chronic Care Markets This resource provides a road map for health plans to improve Medical Loss Ratio. Peer-Reviewed Article February 2018
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
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
Complex Care Program Development: A New Framework for Design and Evaluation A new framework outlines four steps to develop care management programs. Brief/Report 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
The Care Transitions Intervention The Care Transitions Intervention was co-designed with patients and evaluated using randomized trials. Implementation Tool November 2016
Hennepin Health: A Care Delivery Paradigm for New Medicaid Beneficiaries By closing gaps in care, a safety-net ACO has reduced medical costs for Medicaid patients with complex needs. Case Example October 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
Home-Based Care Program Reduces Disability and Promotes Aging in Place Difficulty with activities of daily living is a major cost driver in health care that is typically overlooked. Peer-Reviewed Article September 2016
What Matters Most: Essential Attributes of a High-Quality System of Care for Adults with Complex Care Needs Experts describe how delivery systems can effectively serve adults with complex needs. Brief/Report September 2016
The Hospital at Home Model: Bringing Hospital-Level Care to the Patient The program offers a lower-cost alternative to the hospital for patients who can be safely treated at home. Case Example August 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
So Many Options, Where Do We Start? An Overview of the Care Transitions Literature A systemic review of transitional care interventions reporting hospital readmission Peer-Reviewed Article March 2016
Home-Based Primary Care Interventions Systematic review demonstrates the potential of home-based primary care interventions for improving heath, cost, and patient experience outcomes for adults with multiple chronic conditions and serious disabilities. Peer-Reviewed Article February 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