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

Practice Guide: Integrated Behavioral Health Care for Older Adults

Actionable and evidence-based guidance for integrating behavioral health care into primary care for older adults.

Implementation Tool

June 2023

Equity in CalAIM: How to Identify the Patients Who Will Benefit Most

Rethinking eligibility, beyond cost and utilization, offers a more equitable approach to identify high-need individuals for care management.

Implementation Tool

May 2023

Community Health Worker Model Best Practice Toolkit for Designing, Implementing and Showing Impact

Toolkit provides best practices and practical tools for designing, implementing, and evaluating the impact of community health workers.

Implementation Tool

March 2023

Behavioral Health Integration Playbook

Toolkit offers lessons for integrating behavioral health into primary care settings.

Implementation Tool

June 2022

Telehealth Implementation Playbook

This toolkit shares practical steps and best practices for health care providers and administrators looking to implement telehealth services for their patients.

Implementation Tool

January 2022

Building the Value Case for Complex Care Toolkit

This toolkit can support health care organizations in creating the business case for complex care programs.

Implementation Tool

September 2021

Integrated Care Teams Playbook

Toolkit can help guide implementation of integrated care teams into primary care settings.

Implementation Tool

June 2021

Complex Care Startup Toolkit

Contains practical guides, tools, and other resources for developing complex care programs.

Implementation Tool

June 2021

Health Equity Resource Series: Data-Driven Care Delivery: Data Collection, Stratification and Use

Toolkit details how hospitals and health systems can use patient race, ethnicity, and language data to advance health equity and eliminate disparities.

Implementation Tool

March 2021

Improving Health Care for Adults with Disabilities: An Overview of Federal Data Sources

Health care organizations can use population-level data sources about the experiences of people with disabilities to improve care.

Implementation Tool

December 2020

Operational Guide to Identify, Understand, and Treat High-Need Patients

Offers a practical framework for safety-net health systems to better identify and segment patients with complex needs, and tailor care models to meet their needs.

Implementation Tool

September 2020

Age-Friendly Health Systems: Guide to Using the 4Ms in the Care of Older Adults

Step-by-step guide with robust tools for health systems to apply the 4Ms framework to deliver age-friendly, evidence-based care for older adults.

Implementation Tool

July 2020

Rural Community Paramedicine Toolkit

Toolkit offers health care stakeholders in rural areas with practical information to support the design, implementation, and evaluation of community paramedicine programs.

Implementation Tool

June 2020

Blueprint for Complex Care: Advancing the Field of Care for Individuals with Complex Health and Social Needs

This resource outlines the current state of complex care and recommendations for the future.

Implementation Tool

December 2018

Care Ecosystem Toolkit

Details implementation guidance for the evidence-based Care Ecosystem model, which improves supports for people with dementia and their caregivers.

Implementation Tool

February 2018

Complex Care Management Toolkit

Lessons learned from eight health care organizations can help you design a successful program.

Implementation Tool

April 2012

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

Practice Guide: Integrated Behavioral Health Care for Older Adults

Equity in CalAIM: How to Identify the Patients Who Will Benefit Most

Community Health Worker Model Best Practice Toolkit for Designing, Implementing and Showing Impact

Behavioral Health Integration Playbook

Telehealth Implementation Playbook

Building the Value Case for Complex Care Toolkit

Integrated Care Teams Playbook

Complex Care Startup Toolkit

Health Equity Resource Series: Data-Driven Care Delivery: Data Collection, Stratification and Use

Improving Health Care for Adults with Disabilities: An Overview of Federal Data Sources

Operational Guide to Identify, Understand, and Treat High-Need Patients

Age-Friendly Health Systems: Guide to Using the 4Ms in the Care of Older Adults

Rural Community Paramedicine Toolkit

Blueprint for Complex Care: Advancing the Field of Care for Individuals with Complex Health and Social Needs

Care Ecosystem Toolkit

Complex Care Management Toolkit