The Care Transitions Intervention was co-designed with patients and evaluated using randomized trials.

By closing gaps in care, a safety-net ACO has reduced medical costs for Medicaid patients with complex needs.

Guided Care is designed to strike a balance between telephone-based and interdisciplinary team-based care management programs.

Difficulty with activities of daily living is a major cost driver in health care that is typically overlooked.

Improving care for high-need, high-cost patients is a key lever to decrease national health spending.

The program offers a lower-cost alternative to the hospital for patients who can be safely treated at home.

There is considerable variation in use and spending among high-need adults, suggesting this population should be segmented into subgroups.

Federal policy changes have made PCC models of care more financially viable.

Provider incentives must be based on Triple Aim outcomes.

A standardized tool to assess where along a continuum a program lies with regard to components of integration.

A study of five programs identified key factors that support collaboration among community-based health and social services.

There are many promising strategies to segment individuals with complex needs. Here is one conceptual framework.

In nursing homes, replacing on-call physician services during off-hours with direct contact via telemedicine may reduce Medicare spending through fewer avoidable hospitalizations.

A study showed that some programs reduced hospitalizations by 8 to 33 percent.