Resources

To improve the quality and value of care and target interventions most effectively, it is important to understand the distinction between individuals with complex health and social needs who have...
The Return-on-Investment (ROI) Calculator for Partnerships to Address the Social Determinants of Health, developed by The Commonwealth Fund, is designed to help support successful financial...
Cityblock Health provides care to populations with high rates of social, behavioral, and health risk factors, many of whom are at higher risk for complications from COVID-19. Cityblock developed a...
Effective patient-centered case management interventions can potentially improve health and social outcomes for individuals experiencing homelessness or housing instability. This literature review...
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...
Interventions targeting frequent emergency department (ED) users are increasingly common, but many are developed with limited understanding of this population’s comprehensive use of medical and social...
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 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 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...
This resource assesses the characteristics and health care utilization of high-cost patients and compares high-cost patients across payers and countries, based on a systematic review of studies in...
This resource describes a study assessing the effects of patient activation and engagement strategies on patient-reported outcomes for patients with diabetes and/or cardiovascular and comorbid mental...