Resources

The coronavirus pandemic intensified the already pressing need for the communication and symptom management expertise of palliative care specialists. Amid the surge of COVID-19 cases in New York City...
To improve health outcomes and reduce health care costs and utilization for people with complex needs, it is important to understand the underlying social and behavioral issues that may be driving...
While high-cost patients include diverse subgroups with varying clinical and social needs, efforts to improve the efficiency of care and target interventions have been limited by the lack of knowledge...
Incorporating patient self-reported data may allow health systems to more effectively identify specific groups of older adults with unique needs, thereby helping to inform the development of patient...
This resource used national survey data from physician practices and ACOs, paired with qualitative interviews, to learn about home visiting programs. ACO practices were more likely to report using...
This resource describes a national survey of ACOs about initiatives to address serious illness, as well as follow-up case studies. Only 8–21 percent of ACOs have widely implemented serious illness...
This resource identifies challenges faced by older adults from racial and ethnic minorities, and proposes several strategies to address them. Older adults from racial and ethnic minorities face...
This resource describes an effort to apply a learning health systems approach to reducing ED utilization. A learning health system focuses on improving people’s health at scale through continuous...
This resource is a study evaluating an alternative in-hospital assessment to determine the need for continuing care after discharge. In the UK, a long and complicated Continuing Health Care (CHC)...
This resource is a study undertaken to understand the experiences of older adults living in community settings with multiple chronic conditions. Common themes for study participants included depending...
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...
This resource provides an evaluation of a health system’s outpatient complex case management (OPCM) program and examines whether OPCM lowers service utilization and health care costs. U.S. health...