Health System Performance for the High-Need Patient: A Look at Access to Care and Patient Care Experiences One in five high-need adults reported having an unmet medical need. Brief/Report 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
Person-Centered Care: The Business Case Federal policy changes have made PCC models of care more financially viable. Brief/Report June 2016
Payment to Promote Sustainability of Care Management Models for High-Need, High-Cost Patients Provider incentives must be based on Triple Aim outcomes. Brief/Report May 2016
Taxonomy of Long-Term Services and Supports Integration A standardized tool to assess where along a continuum a program lies with regard to components of integration. Implementation Tool April 2016
Key Components for Successful LTSS Integration: Lessons from Five Exemplar Plans Successful long-term services and supports programs have a single point of accountability, such as a care manager. Brief/Report April 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
Bridging the Silos of Service Delivery for High-Need, High-Cost Individuals A study of five programs identified key factors that support collaboration among community-based health and social services. Peer-Reviewed Article March 2016
Evidence on the Green House Model of Nursing Home Care: Synthesis of Findings and Implications for Policy, Practice, and Research A large study on the Green House nursing home model finds promising evidence for improved quality of care and offers implementation recommendations. Peer-Reviewed Article February 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
Initial Recommendations to Improve the Financing of Long-Term Care Well-designed federal policies can help meet the rising need. Brief/Report February 2016
How High-Need Patients Experience the Health Care System in Nine Countries The U.S. had the highest rate of cost-related access problems. Brief/Report January 2016
Overview of Segmentation of High-Need, High-Cost Patient Population There are many promising strategies to segment individuals with complex needs. Here is one conceptual framework. Implementation Tool January 2016
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 January 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
Targeting Socially Isolated Older Adults: A Process Evaluation of the Senior Centre Without Walls Social and Educational Program A telephone-based virtual senior center may help minimize social isolation and loneliness for older adults. Peer-Reviewed Article December 2015
High-Intensity Telemedicine Decreases Emergency Department Use for Ambulatory Care Sensitive Conditions by Older Adult Senior Living Community Residents Telemedicine may expand access to acute illness care and reduce emergency department visits for older adults. Peer-Reviewed Article December 2015
Person-Centered Care: A Definition and Essential Elements This resource provides a definition and essential elements of person-centered care. Peer-Reviewed Article December 2015
Attributes Common to Programs That Successfully Treat High-Need, High-Cost Individuals Targeting is important, even within the high-need patients enrolled in the program. Peer-Reviewed Article November 2015