Resources

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 four care management models that ACOs are using for individuals with complex needs. Care management programs can involve creating patient care plans, coordinating care across...
The Massachusetts Health Policy Commission's Community Hospital Acceleration, Revitalization, and Transformation (CHART) investment program has engaged 25 community hospitals to advance readiness for...
​​​​ This resource describes a program in New Mexico that employs community health workers (CHWs) to address social determinants of health, as well as how that program was implemented and spread. CHWs...
This resource is a case study of CareMore, a Medicare Advantage plan and medical provider based in Cerritos, California, that serves 130,000 enrollees in Medicare and Medicaid managed care plans...
This resource summarizes a descriptive study of the Health Resilience Program (HRP) in Oregon, a program designed to address the needs of high-risk Medicaid and Medicare patients and reduce costs. In...
This resource provides an in-depth look at the Stanford Coordinated Care Primary Care Practice (SCC), which delivers primary care to Stanford University employees and their dependents who have complex...
This resource reviews the case for segmenting patients with complex needs and different ways of segmenting, as well as challenges and limitations. The high-need, high-cost population is heterogeneous...
This resource is a slide set outlining a project to adapt the Camden Coalition of Healthcare Providers high-utilizer care coordination model to four other sites. Enrollment criteria for the Camden...
This resource is a case study of MedStar Washington Hospital Center’s Medical House Call Program, which offers home-based primary care to patients who are too sick, frail, or disabled to come to a...
This resource describes the Guided Care model of care management and its implementation in two health systems: Lahey Health of Burlington, Massachusetts, and Holy Family Memorial of Manitowoc County...
This resource is a case study of the Hospital at Home program at Presbyterian Healthcare Services in Albuquerque, New Mexico, which offers patients who require hospitalization for conditions with well...