Segmentation framework with publicly available code files identifies specific and actionable patient cohorts with complex needs.

Provides practical steps for current or potential future Medicare accountable care organizations to transform the delivery of care, including through telehealth, home visits, and skilled nursing care.

Contains strategies, tips, and case studies to assist health care stakeholders in building meaningful, person-centered engagement in their organizations.

A set of resources and strategies to help health care stakeholders foster authentic, effective community engagement that drives local policy and program change.

Four care management models for ACOs.

How ACOs can improve care coordination.

A web-based financial tool that helps navigate partnerships between health care organizations and social service organizations.

This resources describes the competencies organizations need to transition to value-based payment.

A standardized tool to assess where along a continuum a program lies with regard to components of integration.

There are many promising strategies to segment individuals with complex needs. Here is one conceptual framework.