Resources

This resource is a toolkit highlighting innovative care coordination strategies used by Medicare ACOs. ACOs use a variety of methods to coordinate and manage the care of their populations, including...
This resource is a toolkit for identifying patients with various physical, functional, emotional, social, and spiritual needs. Patients and families living with serious illness have a range of needs...
This resource offers a variety of materials about “personas” for different segments of the high-need patient population. A persona helps depict the experiences, motivations, and goals of a group of...
This resource, the Accountable Care Atlas, is intended to help health care delivery systems identify and prioritize the competencies needed under risk-based payment. Experts agree that value-based...
This resource is a Disability-Competent Care Self-Assessment Tool. It was developed to help health plans and health systems evaluate their own ability to meet the needs of adults with functional...
This resource provides step-by-step guidance for clinicians engaging in conversation with patients about serious illness. The basic steps are: set up the conversation; assess understanding and...
This resource offers a structured improvement process for redesigning care for people with complex needs and high health care costs. This guide harvests the experience of over 200 organizations who...