Resources

Care coordination programs for individuals with multiple chronic conditions and unmet social needs can be operationally complex, but little research has been done on staff effort within these programs...
Adventist Health Clear Lake, a health system in rural California, initiated a cross-sector collaboration between rural service providers and community agencies to more effectively address the needs of...
How can health care systems across the nation effectively address social needs? An expert committee created by the National Academies of Sciences, Engineering, and Medicine (NASEM) sought to address...
Incorporating patient self-reported data may allow health systems to more effectively identify specific groups of older adults with unique needs, thereby helping to inform the development of patient...
Improving transitions between care settings is critical to achieving positive health outcomes and enhanced quality of life, particularly for dually eligible beneficiaries navigating fragmented...
A telephone-based social needs screening, referral, and navigation program that focused on patients with predicted high utilization within the Kaiser Permanente Southern California health system...
Providing supportive housing for individuals experiencing homelessness who are identified as active substance users resulted in lower rates of SUD-related ED visits and hospitalizations compared to...
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...
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 the Great Plains Senior Services Collaborative, an initiative to improve health and quality of life for rural seniors. Populations of rural seniors face significant challenges...
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 study compared health services use and costs depending on whether the primary care provider was a physician, NP, or PA. NPs and PAs are taking a larger role in the primary care of medically...