The Guide to Integrating Palliative Care into Population Management Practical strategies for health plans and ACOs to improve care for patients with serious illness. Implementation Tool February 2019
Quick Reference Guide to Promising Care Models This resource is an updated quick reference guide to promising models for people with complex needs. Brief/Report February 2019
How Accountable Care Organizations Use Population Segmentation to Care for High-Need, High-Cost Patients Accountable Care Organization leaders explore approaches to segmenting high-need, high-cost populations. Brief/Report January 2019
How ACOs Are Caring for People with Complex Needs An analysis of the National Survey of ACOs Brief/Report December 2018
The ROI Calculator for Partnerships to Address the Social Determinants of Health A web-based financial tool that helps navigate partnerships between health care organizations and social service organizations. Implementation Tool August 2018
Patient Engagement in ACO Practices and Patient-Reported Outcomes Among Adults with Co-Occurring Chronic Disease and Mental Health Conditions Patient engagement improves patient-reported outcomes. Peer-Reviewed Article July 2018
Ten Questions to Better Understand and Serve Your Complex Care Population California is asking Medicaid patients these ten questions about social and functional needs. Brief/Report April 2018
The CHRONIC Care Act of 2018: Advancing Care for Adults with Complex Needs A brief summarizes what you need to know about the new Chronic Care Act. Brief/Report 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
Managing Effectively in Complex Chronic Care Markets This resource provides a road map for health plans to improve Medical Loss Ratio. Peer-Reviewed Article February 2018
Accountable Care Atlas: A Development Guide for Competency Implementation This resources describes the competencies organizations need to transition to value-based payment. Implementation Tool November 2017
Toward a Serious Illness Program Design and Implementation Framework This framework can help you design programs for patients with serious illnesses. Peer-Reviewed Article August 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
Integrating Health Care for High-Need Medicaid Beneficiaries With Serious Mental Illness and Chronic Physical Health Conditions at Managed Care, Provider, and Consumer Levels This resource describes the value of navigators for Medicaid beneficiaries with mental illness. Peer-Reviewed Article 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
Medicaid Managed Care Best Practices Compendium This resource collects the most innovative initiatives in Medicaid managed care that emerge each year. Brief/Report January 2017
The Care Transitions Intervention The Care Transitions Intervention was co-designed with patients and evaluated using randomized trials. Implementation Tool November 2016
Hennepin Health: A Care Delivery Paradigm for New Medicaid Beneficiaries By closing gaps in care, a safety-net ACO has reduced medical costs for Medicaid patients with complex needs. Case Example October 2016
Guided Care: A Structured Approach to Providing Comprehensive Primary Care for Complex Patients Guided Care is designed to strike a balance between telephone-based and interdisciplinary team-based care management programs. Case Example October 2016
Home-Based Care Program Reduces Disability and Promotes Aging in Place Difficulty with activities of daily living is a major cost driver in health care that is typically overlooked. Peer-Reviewed Article September 2016