Resources

Complex care programs across the country use varied criteria to identify people with complex health and social needs and measure the effectiveness of subsequent interventions. Greater standardization...
To improve health outcomes and reduce health care costs and utilization for people with complex needs, it is important to understand the underlying social and behavioral issues that may be driving...
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...
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...
Family caregivers are a critical part of the home- and community-based workforce for people with serious illness. This is particularly the case for veterans, who are often sicker than the general...
This resource provides guidelines for implementing Special Supplemental Benefits for the Chronically Ill (SSBCI) in a manner that improves health care for chronically ill Medicare beneficiaries. The...
This resource used national survey data from physician practices and ACOs, paired with qualitative interviews, to learn about home visiting programs. ACO practices were more likely to report using...
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 describes a national survey of ACOs about initiatives to address serious illness, as well as follow-up case studies. Only 8–21 percent of ACOs have widely implemented serious illness...
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 identifies challenges faced by older adults from racial and ethnic minorities, and proposes several strategies to address them. Older adults from racial and ethnic minorities face...
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...