Person-Centered Engagement at the Organizational Level

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

Implementation Tool

January 2020

Medicare-Medicaid Integration: A Reference Guide to Emerging Evidence and Technical Assistance Tools

This reference guide summarizes a set of curated resources to help key stakeholders better understand both the needs of the dually eligible population and emerging evidence and practical approaches for advancing Medicare-Medicaid integration.

Implementation Tool

January 2021

Strategies for Hiring and Training Care Managers in Integrated Programs Serving Medicare-Medicaid Beneficiaries

Describes practical health plan strategies for hiring and training care managers for dual eligible enrollees with complex needs.

Implementation Tool

February 2015

The Guide to Integrating Palliative Care into Population Management

Practical strategies for health plans and ACOs to improve care for patients with serious illness.

Implementation Tool

February 2019

Taxonomy of Long-Term Services and Supports Integration

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

Implementation Tool

April 2016

The Opioid Use Disorder Prevention Playbook

Strategies for preventing opioid use disorder.

Implementation Tool

February 2019

AAHCM Toolkit: Building Awareness and Engaging Payers to Bring Home-Based Primary Care into the Mainstream

The benefits of home-based primary care.

Implementation Tool

June 2019

Patient Identification and Assessment

A toolkit for assessing patient needs.

Implementation Tool

March 2019

Health Care Transformation Task Force Value Partnership Evaluation Tool

A tool for assessing readiness for value-based partnerships.

Implementation Tool

March 2019

The ROI Calculator for Partnerships to Address the Social Determinants of Health

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

Implementation Tool

August 2018

Care Management Contracting for Complex Populations: Best Practices and Tools

This resource offers guidance on contracting for populations with complex needs.

Implementation Tool

July 2018

Investing in Social Services as a Core Strategy for Healthcare Organizations: Developing the Business Case

This resource explains how to invest in social services as a business strategy.

Implementation Tool

March 2018

Disability-Competent Care Self-Assessment Tool

How disability-competent is your organization?

Implementation Tool

October 2017

Care Redesign Guide: Better Health and Lower Costs for People with Complex Needs

The Care Redesign Guide offers a structured improvement process for redesigning care.

Implementation Tool

February 2017

Intensive Outpatient Care Program Toolkit

The staff position of care coordinator is crucial to success.

Implementation Tool

December 2016

Overview of Segmentation of High-Need, High-Cost Patient Population

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

Implementation Tool

January 2016

Pursuing Financial Sustainability of Person-Centered Care Models

Setting up data collection systems is important to showing value.

Implementation Tool

January 2014

Improving Care for People with Serious Illness Through Innovative Payer-Provider Partnerships

The benefits of, incentives for, and various models to deliver palliative care are described.

Implementation Tool

January 2014

The Return on Investment (ROI) Calculator: The Business Case and Person-Centered Care

A calculator that can help build and present business case for serving adults with complex needs.

Implementation Tool

November 2016

The Care Transitions Intervention

The Care Transitions Intervention was co-designed with patients and evaluated using randomized trials.

Implementation Tool

November 2016

All Resources

All Resources

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Content Types

Person-Centered Engagement at the Organizational Level

Medicare-Medicaid Integration: A Reference Guide to Emerging Evidence and Technical Assistance Tools

Strategies for Hiring and Training Care Managers in Integrated Programs Serving Medicare-Medicaid Beneficiaries

The Guide to Integrating Palliative Care into Population Management

Taxonomy of Long-Term Services and Supports Integration

The Opioid Use Disorder Prevention Playbook

AAHCM Toolkit: Building Awareness and Engaging Payers to Bring Home-Based Primary Care into the Mainstream

Patient Identification and Assessment

Health Care Transformation Task Force Value Partnership Evaluation Tool

The ROI Calculator for Partnerships to Address the Social Determinants of Health

Care Management Contracting for Complex Populations: Best Practices and Tools

Investing in Social Services as a Core Strategy for Healthcare Organizations: Developing the Business Case

Disability-Competent Care Self-Assessment Tool

Care Redesign Guide: Better Health and Lower Costs for People with Complex Needs

Intensive Outpatient Care Program Toolkit

Overview of Segmentation of High-Need, High-Cost Patient Population

Pursuing Financial Sustainability of Person-Centered Care Models

Improving Care for People with Serious Illness Through Innovative Payer-Provider Partnerships

The Return on Investment (ROI) Calculator: The Business Case and Person-Centered Care

The Care Transitions Intervention