All Resources

Understanding the Medicare Physician Fee Schedule Billing Codes For: Community Health Integration, Principal Illness Navigation, and Principal Illness Navigation-Peer Support Services

This toolkit details options for implementing recently introduced Medicare services that address members’ health-related social needs.

Implementation Tool

March 2024

Partnerships with Community-Based Organizations: Opportunities for Health Plans to Create Value

This resource guide outlines the value case for health plans to partner with community-based organizations for social care benefits.

Implementation Tool

June 2023

Functions of a Mature Community Care Hub

The community care hub model can support facilitating strong partnerships between community-based organizations and health care organizations.

Implementation Tool

June 2023

Addressing Social Isolation and Loneliness Among Older Dually Eligible Individuals

Toolkit offers recommendations and examples for screening and interventions that support social connectivity of older adults.

Implementation Tool

November 2022

Guide to Evidence for Health-Related Social Needs Interventions: 2022 Update

Summarizes evidence on costs of health-related social needs interventions and their impact on utilization and cost of care to inform ROI Calculator users.

Implementation Tool

September 2022

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

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

All Resources

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State

Understanding the Medicare Physician Fee Schedule Billing Codes For: Community Health Integration, Principal Illness Navigation, and Principal Illness Navigation-Peer Support Services

Partnerships with Community-Based Organizations: Opportunities for Health Plans to Create Value

Functions of a Mature Community Care Hub

Addressing Social Isolation and Loneliness Among Older Dually Eligible Individuals

Guide to Evidence for Health-Related Social Needs Interventions: 2022 Update

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

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