Accountable care organization leaders share perspectives on payment mechanisms used with social service organizations, challenges experienced, and the impacts of these partnerships.
Patients and community health workers (CHWs) share perspectives on the impact of CHW services provided within a primary care setting to address barriers to equitable care.
Explored how complex care stakeholders can incorporate a multi-factor approach to measure and demonstrate the value of complex care programs for diverse stakeholders.
Varying structures of cross-sector partnerships between health care organizations, social service agencies, and local government bodies have distinct strengths and serve different functions.
Differing patterns of care utilization and mortality outcomes within subgroups of a complex patient population can help inform more targeted care interventions.
Global budgets for hospitals reduced expenditures and utilization for some Medicare subpopulations with complex health and social needs, yet disparities existed for some subgroups.
Using segmentation to address clinical and social needs for Medicaid patients with complex needs and costly utilization can improve the effectiveness of complex care programs.
Home-based palliative care program implemented within an accountable care organization created cost savings through reduced hospital admissions and increased hospice length of stay.
An interdisciplinary team approach can improve care coordination and reduce length of hospital stays for older adults with complex health and social needs.
Describes electronic health record system functionality that automatically identifies patients likely to need technical assistance prior to telehealth visits.