Resources

Understanding where and how high-risk patients receive care can inform efforts to improve care for this population. This study observed care patterns for more than 350,000 high-risk patients within...
While community health worker (CHW) programs that serve low-income populations have demonstrated reductions in preventable acute care utilization, these programs often have limited funding. Developing...
Adults with serious mental illness (SMI) are at much greater risk than the general population for cardiovascular disease, and require tailored interventions to address co-occurring cardiovascular risk...
Low-income individuals with diabetes who experience unstable housing and food insecurity are likely to have increased emergency department (ED) visits and hospitalizations. This study evaluated the...
Individuals with serious mental illness (SMI) have high preventable emergency department (ED) usage, often due to poorly managed chronic medical conditions. A North Carolina primary care center...
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...
Whole Person Care (WPC) pilots, under California’s Medicaid Section 1115(a) waiver demonstration, integrate medical, behavioral health, and social needs services to improve the health and wellbeing of...
Health care organizations are increasingly partnering with Area Agencies on Aging (AAAs) to provide social needs support for older adults in the community who are identified with high health risks...
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...
Engaging patients in shared decision-making requires providers to integrate patient-identified goals into patient-provider communications. This qualitative study explored how high-need, high-cost...
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...
Individualized Management for Patient-Centered Targets (IMPaCT) is an intervention that employs community health workers to provide tailored social support to high-risk patients informed by patient...