Resources

A telephone-based social needs screening, referral, and navigation program that focused on patients with predicted high utilization within the Kaiser Permanente Southern Cal

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

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

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

This resource describes and evaluates a new specialist pharmacy service, called the integrated care clinical pharmacist.

This resource describes a national survey of ACOs about initiatives to address serious illness, as well as follow-up case studies.

This resource identifies challenges faced by older adults from racial and ethnic minorities, and proposes several strategies to address them.

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

This resource is a study undertaken to understand the experiences of older adults living in community settings with multiple chronic conditions.

This resource provides an overview of a quality-improvement intervention focused on communication with patients with advanced cancer.