Resources

Individualized Management for Patient-Centered Targets (IMPaCT) is an intervention that employs community health workers to provide tailored social support to high-risk patients informed by patient...
High-need, high-cost Medicaid patients enrolled in a 12-month complex care management program at CareMore Health in Memphis, Tennessee experienced reductions of 59 percent in inpatient utilization and...
A randomized controlled trial found that the “Camden Core Model,” a short-term care management program for individuals with complex health and social needs and multiple recent hospital admissions, did...
How can health care systems across the nation effectively address social needs? An expert committee created by the National Academies of Sciences, Engineering, and Medicine (NASEM) sought to address...
Providing supportive housing for individuals experiencing homelessness who are identified as active substance users resulted in lower rates of SUD-related ED visits and hospitalizations compared to...
This resource describes a quasi-experimental study evaluating the effect of a transitional care program that involved rapid primary care follow-up for Medicaid and Medicare patients with complex needs...
This resource describes a new model that moves high-need patients out of the emergency department and into a network of social supports. Regional One Health, a large health system in Tennessee, has...
This resource describes the Great Plains Senior Services Collaborative, an initiative to improve health and quality of life for rural seniors. Populations of rural seniors face significant challenges...
This resource describes and evaluates a new specialist pharmacy service, called the integrated care clinical pharmacist. Older people confined to their own homes due to are known to be at risk of...
This resource is a toolkit to help payers and providers understand how home-based primary care (HBPC) improves quality and reduces costs for seriously ill and home-limited older adults. HBPC providers...
This resource provides an example of an approach to caring for different subpopulations of people with dementia. UCLA Health adopted a structure that identifies people living with dementia, then...
This resource describes a randomized controlled trial to evaluate the effects of a case management intervention called V1SAGES (Vulnerable Patients in Primary Care: Nurse Case Management and Self...