Going Beyond Clinical Care to Reduce Health Care Spending A regional approach to health care transformation. Peer-Reviewed Article July 2018
Case Management in Primary Care for Frequent Users of Health Care Services: A Mixed Methods Study The psychological benefits of case management. Peer-Reviewed Article May 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
The Effects of Home-Based Primary Care on Medicare Costs at Spectrum Health/Priority Health from 2012-Present: A Matched Cohort Study A home-based primary care program led to reduced medical costs for frail elderly patients, primarily due to lower spending at end-of-life. Peer-Reviewed Article March 2018
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
Building Complex Care Programs: A Road Map for States This guide for state leaders offers lessons about state-level approaches to complex care. Implementation Tool October 2017
Designing a Health Care System for Patients with Complex Needs: Ten Recommendations for Policymakers An international expert group offers ten policy recommendations and profiles of innovative care models. Brief/Report September 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
Bending the Spending Curve: The Role of Care Management in a Pioneer ACO ACOs have lowered costs for high-need patients through care management programs focused on modifiable spending. Peer-Reviewed Article May 2017
Preventing Hospitalization with Veterans Affairs Home-Based Primary Care: Which Individuals Benefit Most? Home-based primary care program reduced hospitalizations for older adults with diabetes, especially those with higher levels of medical complexity. Peer-Reviewed Article 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
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
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
The Health Resilience Program: A Program Assessment Health Resilience Specialists work with the patients to meet their personal health needs Case Example January 2016
Supporting a Culture of Health: Opportunities to Improve Models of Care for People with Complex Needs Key opportunities include strengthening information technology connections across service providers. Brief/Report September 2015