Resources

Accountable care organizations (ACOs) have shown promise in improving care for individuals with chronic conditions who also have coexisting mental health conditions, in part by incentivizing hospitals...
This analysis compared Medicare Advantage (MA) enrollees’ demographic, socioeconomic, and clinical characteristics plus health care utilization, spending, and quality of care in 2012 and 2015, and...
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...
Whole Person Care (WPC) pilots, under California’s Medicaid Section 1115(a) waiver demonstration, integrate medical, behavioral health, and social needs services to improve the health and wellbeing of...
Health care organizations are increasingly partnering with Area Agencies on Aging (AAAs) to provide social needs support for older adults in the community who are identified with high health risks...
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...
Engaging patients in shared decision-making requires providers to integrate patient-identified goals into patient-provider communications. This qualitative study explored how high-need, high-cost...
Many older adults experience loneliness, which can lead to harmful impacts on mental as well as physical health. This literature review evaluated the effectiveness of published studies of...
Many older adults in the United States experience social isolation and loneliness, which are associated with increased risks for premature mortality, dementia, and other poor health outcomes. Since...
The causes of social isolation and loneliness in older adults, including their health, income, and place of residence, may impede their ability to participate in community-based social activities...
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...
Interventions targeting frequent emergency department (ED) users are increasingly common, but many are developed with limited understanding of this population’s comprehensive use of medical and social...