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.
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.
A cross-sector partnership to enroll older adults experiencing homelessness in permanent supportive housing led to meaningful reductions in health care costs.
CAPABLE, a home-based care program that provides interdisciplinary services for older adults, leads to reductions in disability as well as cost savings.
Offers practical recommendations to improve telemedicine interventions to be more equitable for diverse populations, particularly those with low incomes.
Case study of interdisciplinary primary care program for high-risk patients based at an academic health system offers lessons on program design and implementation.
During the COVID-19 pandemic, Cityblock Health implemented a virtually integrated care management model to maintain continuity of care for patients with complex needs.
Primary care and alternative payment models that reduce emergency department use and increase access to care for high-need populations share core components for success.
Home-based program provided by a community health and social worker reduces acute care use and improves care for older adults with complex health and social needs.