Resources

A telephone-based social needs screening, referral, and navigation program that focused on patients with predicted high utilization within the Kaiser Permanente Southern Cal

This resource describes a quasi-experimental study evaluating the effect of a transitional care program that involved rapid primary care follow-up

This resource describes a new model that moves high-need patients out of the emergency department and into a network of social supports.

Family caregivers play a foundational role in the care of older adults with complex needs and disabilities from both a health care and economic standpoint.

Family caregivers are a critical part of the home- and community-based workforce for people with serious illness.

This resource describes and evaluates a new specialist pharmacy service, called the integrated care clinical pharmacist.

This resource is a toolkit to help payers and providers understand how home-based primary care (HBPC) improves quality and reduces costs for seriously ill and home-limited o

This resource provides an example of an approach to caring for different subpopulations of people with dementia. 

This resource describes a randomized controlled trial to evaluate the effects of a case management intervention called V1SAGES (Vulnerable Patients in Primary Care: Nurse Ca

This resource provides an overview of a quality-improvement intervention focused on communication with patients with advanced cancer. 

This resource describes the 7-Day Pledge program to reduce readmissions by increasing access to timely primary care appointments after hospitalization.

Based on a review of the evidence, the Quick Reference Guide to Promising Care Models offers summary information on 2