Resources

A majority of mature accountable care organizations (ACOs) segment their high-need, high-cost (HNHC) population into smaller subgroups to better identify those with similar needs, employing a range of...
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...
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...
Based on a review of the evidence, the Quick Reference Guide to Promising Care Models offers summary information on 28 programs for adults with complex needs, specifically: Target population and...
This resource describes a promising new hospitalist model for inpatient treatment of complex care patients. In July 2016, Commonwealth Care Alliance and Boston Medical Center created a hospitalist...
This resource describes recent changes in Medicare Advantage (MA) and their implications for plans. The Centers for Medicare and Medicaid Services (CMS) has recently reinterpreted several key aspects...
This resource examines three innovative models for treating patients with serious illness, developed by third-party firms that contract with Medicare Advantage plans. The financing structure of...
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 features a recording of a WIHI audio program from the Institute for Healthcare Improvement, which featured Better Care Playbook faculty, including R. Corey Waller, MD, and Catherine...
Throughout the country, efforts are increasingly emerging to integrate social services into health care systems. This resource classifies new initiatives, identifies common challenges, and proposes...
This resource shares 10 questions that California’s Medicaid managed care plans are now required to ask patients about their social and functional needs. These questions could serve as a model for...