Resources

This resource describes a quasi-experimental study evaluating the effect of a transitional care program that involved rapid primary care follow-up

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

Family caregivers are a critical part of the home- and community-based workforce for people with serious illness.

This resource provides a framework for understanding the nature and extent of integration in programs that integrate LTSS with medical care and behavioral health.

This resource used national survey data from physician practices and ACOs, paired with qualitative interviews, to learn about home visiting programs.

This resource analyzes preventable ED visits and identifies mechanisms for preventing them.

This resource is a toolkit to help payers and providers understand how home-based primary care (HBPC) improves quality and reduces costs for seriously ill and home-limited o

This resource describes a randomized controlled trial to evaluate the effects of a case management intervention called V1SAGES (Vulnerable Patients in Primary Care: Nurse Ca

This resource describes an effort to apply a learning health systems approach to reducing ED utilization.

This resource is a toolkit highlighting innovative care coordination strategies used by Medicare ACOs.

This resource is a toolkit for identifying patients with various physical, functional, emotional, social, and spiritual needs.

This resource is a study evaluating an alternative in-hospital assessment to determine the need for continuing care after discharge.