Resources

This resource describes a new model that moves high-need patients out of the emergency department and into a network of social supports.

This resource describes four care management models that ACOs are using for individuals with complex needs.

This resource describes successful Canadian programs working with inner-city communities to achieve the Triple Aim.

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 Massachusetts Health Policy Commission's Community Hospital Acceleration, Revitalization, and Transformation (CHART) investment program has engaged 25 community hospitals to a

​​​​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.

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 ac

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.

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 comp

,

This resource reviews the case for segmenting patients with complex needs and different ways of segmenting, as well as challenges and limitations.

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.

This resource is a case study of the Program of All-Inclusive Care for the Elderly (PACE), focusing on On Lok, the original program.