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...
This resource describes successful Canadian programs working with inner-city communities to achieve the Triple Aim. It includes descriptions of the programs’ structures and outcomes, factors that...
This resource describes the author’s changed understanding of the role of the health system in helping people with complex needs, sparked by an encounter with a vulnerable patient. The author, a nurse...
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 the Program of All-Inclusive Care for the Elderly (PACE), focusing on On Lok, the original program. On Lok Senior Health Services was founded in 1971 in the San...
