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Telehealth in Complex Care

Curates recent evidence behind telehealth-delivered interventions and explore practical tools and case studies to learn considerations and effective strategies to guide implementation of telehealth-delivered programs.

Collection

November 2021

Clinical Outcome and Utilization Profiles Among Latent Groups of High-Risk Patients: Moving from Segmentation Towards Intervention

Differing patterns of care utilization and mortality outcomes within subgroups of a complex patient population can help inform more targeted care interventions.

Peer-Reviewed Article

November 2021

Frontline Provider Perceptions of Implementing Home-Based Palliative Care Covered by an Insurer

Home-based palliative care providers explore key facilitators and barriers to effectively delivering care within a value-based payment environment.

Peer-Reviewed Article

November 2021

Telehealth for Opioid Use Disorder Treatment in Low-Barrier Clinic Settings: An Exploration of Clinician and Staff Perspectives

While telehealth has the potential to increase access to treatment for opioid use disorder, barriers still exist for patients and providers in receiving and delivering virtual care.

Peer-Reviewed Article

November 2021

Supporting Telehealth and Technology-assisted Services for People Who Use Drugs: A Resource Guide

Supports the use of telehealth and technology-assisted services to increase access to care and improve outcomes for people who use drugs.

Implementation Tool

November 2021

Management of High-Need, High-Cost Patients: A “Best Fit” Framework Synthesis, Realist Review, and Systematic Review

Systematic review of programs to improve care for patients with complex needs details evidence base across multiple settings.

Brief/Report

October 2021

Using Patient Segmentation and Data on Health-Related Social Needs to Identify People with Complex Needs

Explored how health care organizations can incorporate a segmentation framework into population health management using simple algorithms.

Webinar

October 2021

High-Need, High-Cost Segmentation Framework

Segmentation framework with publicly available code files identifies specific and actionable patient cohorts with complex needs.

Implementation Tool

October 2021

Effects of Global Budget Payments on Vulnerable Medicare Subpopulations in Maryland

Global budgets for hospitals reduced expenditures and utilization for some Medicare subpopulations with complex health and social needs, yet disparities existed for some subgroups.

Peer-Reviewed Article

October 2021

High-Cost High-Need Patients in Medicaid: Segmenting the Population Eligible for a National Complex Case Management Program

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.

Peer-Reviewed Article

October 2021

Incorporating What Matters Most to Patients into Care Delivery

Details NCQA's person-driven outcome measures and how they can be used to improve care for people with complex health and social needs.

Blog

October 2021

Effects of the Tailored Activity Program (TAP) on Dementia-Related Symptoms, Health Events and Caregiver Well-Being: A Randomized Controlled Trial

Dementia care program delivered by an occupational therapist and tailored to the needs of patients and their caregivers shows improved patient quality of life and caregiver well-being.

Peer-Reviewed Article

October 2021

Pathway Home for High Utilizers of Psychiatric Inpatient Services: Impact on Inpatient Days and Outpatient Engagement

A community-based care transition and management intervention showed improved outcomes for patients transitioning to outpatient community care following a psychiatric hospitalization.

Peer-Reviewed Article

October 2021

Advancing Health Equity for People Who Are Homebound

Explores the epidemiology and characteristics of homebound older adults, inequities they face, and reimagines care delivery for this population.

Blog

September 2021

Strengthening the Payer-Provider Relationship for Value-Based Success in Home- and Community-Based Palliative Care

Looked at the provider and payer relationship and discussed how successful partnerships between these two stakeholders can create sustainable and efficacious home and community based palliative care programs.

Webinar

September 2021

Housecall Providers: Caring for People with Serious Illness Wherever They Call Home

Features Housecall Providers, a non-profit medical provider serving Portland, Oregon, offering comprehensive home- and community-based programs that incorporate palliative care services and provide patient-driven, high-touch support wherever patients call home.

Blog

September 2021

The Impact of a Home-Based Palliative Care Program in an Accountable Care Organization

Home-based palliative care program implemented within an accountable care organization created cost savings through reduced hospital admissions and increased hospice length of stay.

Peer-Reviewed Article

September 2021

Building the Value Case for Complex Care Toolkit

This toolkit can support health care organizations in creating the business case for complex care programs.

Implementation Tool

September 2021

Optimal Staffing Models To Care For Frail Older Adults In Primary Care And Geriatrics Practices In The US

Care team models with more nurse practitioners and physician assistants than physicians are associated with increased primary care and geriatrics services provision and reduced labor costs.

Peer-Reviewed Article

September 2021

From the Hospital to the Streets: Bringing Care to the Unsheltered Homeless in Los Angeles

A street medicine program increased post-hospitalization follow-up care for unsheltered individuals experiencing homelessness in Los Angeles.

Case Example

September 2021

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Telehealth in Complex Care

Clinical Outcome and Utilization Profiles Among Latent Groups of High-Risk Patients: Moving from Segmentation Towards Intervention

Frontline Provider Perceptions of Implementing Home-Based Palliative Care Covered by an Insurer

Telehealth for Opioid Use Disorder Treatment in Low-Barrier Clinic Settings: An Exploration of Clinician and Staff Perspectives

Supporting Telehealth and Technology-assisted Services for People Who Use Drugs: A Resource Guide

Management of High-Need, High-Cost Patients: A “Best Fit” Framework Synthesis, Realist Review, and Systematic Review

Using Patient Segmentation and Data on Health-Related Social Needs to Identify People with Complex Needs

High-Need, High-Cost Segmentation Framework

Effects of Global Budget Payments on Vulnerable Medicare Subpopulations in Maryland

High-Cost High-Need Patients in Medicaid: Segmenting the Population Eligible for a National Complex Case Management Program

Incorporating What Matters Most to Patients into Care Delivery

Effects of the Tailored Activity Program (TAP) on Dementia-Related Symptoms, Health Events and Caregiver Well-Being: A Randomized Controlled Trial

Pathway Home for High Utilizers of Psychiatric Inpatient Services: Impact on Inpatient Days and Outpatient Engagement

Advancing Health Equity for People Who Are Homebound

Strengthening the Payer-Provider Relationship for Value-Based Success in Home- and Community-Based Palliative Care

Housecall Providers: Caring for People with Serious Illness Wherever They Call Home

The Impact of a Home-Based Palliative Care Program in an Accountable Care Organization

Building the Value Case for Complex Care Toolkit

Optimal Staffing Models To Care For Frail Older Adults In Primary Care And Geriatrics Practices In The US

From the Hospital to the Streets: Bringing Care to the Unsheltered Homeless in Los Angeles