A New Hospitalist Model for Managing High-Cost, High-Need Patients
A hospitalist model for complex care.
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Displaying 121 - 140 of 141
Are Social Workers Missing from Your Complex Care Teams?
Many studies have highlighted the importance of effective interprofessional care teams to improve health outcomes for people with complex needs. But many programs do not take advantage of the special training of social workers to meet these needs on their primary health care teams.
Blog
June 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
Integrate Health Coaches into the Care Team
Health coaching can play an especially important role for patients with complex needs, who may struggle to manage multiple conditions, multiple providers, and services outside the health system.
Play
February 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
Compendium of Five Case Studies: Lessons for Interprofessional Teamwork
The VA shares lessons on workforce learning and development.
Brief/Report
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
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
The Cost-Effectiveness of Clinical Nurse Specialist–Led Interventions in Palliative Care
Clinical Nurse Specialists are playing a greater role in palliative care, but evidence on their cost-effectiveness is mixed.
Peer-Reviewed Article
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
Peer Support Toolkit
Details the key considerations for providers considering integrating peer services for behavioral health into their health care organizations.
Implementation Tool
Nursing Student Coaches for Emergency Department Super Utilizers
Nursing students successfully coach patients with complex needs to avoid ED use.
Peer-Reviewed Article
Effect of a Home-Based Palliative Care Program on Healthcare Use and Costs
A home-based palliative care program using an interdisciplinary care team reduces hospital costs and unnecessary health care utilization for Medicare Advantage beneficiaries.
Peer-Reviewed Article
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
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
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
Community Care Teams: An Overview of State Approaches
The composition of teams varies depending on state staffing requirements and community resources.
Brief/Report
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
Multiple Chronic Conditions: A Framework for Education and Training
A framework describes how to train the health care workforce to care for people with multiple chronic conditions.
Implementation Tool