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New Models of Primary Care Workforce and Financing: Case Example #1: Stanford Coordinated Care

Stanford Coordinated Care provides university employees with complex health needs better care at a lower cost

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

What Matters Most: Essential Attributes of a High-Quality System of Care for Adults with Complex Care Needs

Experts describe how delivery systems can effectively serve adults with complex needs.

Brief/Report

September 2016

Delivery System Reform: Improving Care for Individuals Dually Eligible for Medicare and Medicaid

Dual-eligible beneficiaries are often more sick, have greater functional and cognitive impairments, and require more care coordination.

Brief/Report

September 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

Tailoring Complex Care Management, Coordination, and Integration for High-Need, High-Cost Patients

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

Brief/Report

September 2016

A Systematic Review of Evidence for the Clubhouse Model of Psychosocial Rehabilitation

“Clubhouses” for people with serious mental illness are effective at promoting employment, reducing hospitalizations, and improving quality of life.

Peer-Reviewed Article

August 2016

Aging Gracefully: The PACE Approach to Caring for Frail Elders in the Community

Reviews lessons from the Program of All-Inclusive Care for the Elderly on serving high-need populations in community settings.

Case Example

August 2016

The Hospital at Home Model: Bringing Hospital-Level Care to the Patient

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

Case Example

August 2016

Improving Population Health Management Strategies: Identifying Likely Users of Avoidable Costly Care

Assessing patients’ activation levels can help identify those at risk for poor health outcomes and utilization of avoidable, costly care.

Peer-Reviewed Article

August 2016

The Core of Care Management: The Role of Authentic Relationships in Caring for Patients with Frequent Hospitalizations

This study links “authentic healing relationships” with patient motivation and active health management.

Peer-Reviewed Article

August 2016

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

Project ECHO’s Complex Care Initiative: Building Capacity to Help “Superutilizers”

Interdisciplinary teams provide support for Medicaid beneficiaries with mental illnesses, addictions, and other needs.

Case Example

August 2016

Leveraging the Social Determinants of Health: What Works?

This literature review assesses the impact of social service interventions.

Peer-Reviewed Article

August 2016

High-Need, High-Cost Patients: Who Are They and How Do They Use Health Care?

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

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

Characteristics of Hospital and Emergency Care Super-Utilizers with Multiple Chronic Conditions

Patients with a history of high health care utilization may be a good target for a care transition intervention

Peer-Reviewed Article

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

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New Models of Primary Care Workforce and Financing: Case Example #1: Stanford Coordinated Care

Guided Care: A Structured Approach to Providing Comprehensive Primary Care for Complex Patients

What Matters Most: Essential Attributes of a High-Quality System of Care for Adults with Complex Care Needs

Delivery System Reform: Improving Care for Individuals Dually Eligible for Medicare and Medicaid

Home-Based Care Program Reduces Disability and Promotes Aging in Place

Tailoring Complex Care Management, Coordination, and Integration for High-Need, High-Cost Patients

A Systematic Review of Evidence for the Clubhouse Model of Psychosocial Rehabilitation

Aging Gracefully: The PACE Approach to Caring for Frail Elders in the Community

The Hospital at Home Model: Bringing Hospital-Level Care to the Patient

Improving Population Health Management Strategies: Identifying Likely Users of Avoidable Costly Care

The Core of Care Management: The Role of Authentic Relationships in Caring for Patients with Frequent Hospitalizations

Health System Performance for the High-Need Patient: A Look at Access to Care and Patient Care Experiences

Project ECHO’s Complex Care Initiative: Building Capacity to Help “Superutilizers”

Leveraging the Social Determinants of Health: What Works?

High-Need, High-Cost Patients: Who Are They and How Do They Use Health Care?

Bringing Primary Care Home: The Medical House Call Program at MedStar Washington Hospital Center

Person-Centered Care: The Business Case

Payment to Promote Sustainability of Care Management Models for High-Need, High-Cost Patients

Characteristics of Hospital and Emergency Care Super-Utilizers with Multiple Chronic Conditions

Key Components for Successful LTSS Integration: Lessons from Five Exemplar Plans