Resources

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...
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...
High-need, high-cost Medicaid patients enrolled in a 12-month complex care management program at CareMore Health in Memphis, Tennessee experienced reductions of 59 percent in inpatient utilization and...
Project ECHO (Extension for Community Health Outcomes) virtually connects specialists with community-based providers to help improve patient care management. This evaluation of the ECHO Care pilot...
A randomized controlled trial found that the “Camden Core Model,” a short-term care management program for individuals with complex health and social needs and multiple recent hospital admissions, did...
A telephone-based social needs screening, referral, and navigation program that focused on patients with predicted high utilization within the Kaiser Permanente Southern California health system...
This resource describes a quasi-experimental study evaluating the effect of a transitional care program that involved rapid primary care follow-up for Medicaid and Medicare patients with complex needs...
This study compared health services use and costs depending on whether the primary care provider was a physician, NP, or PA. NPs and PAs are taking a larger role in the primary care of medically...
This resource describes and evaluates a new specialist pharmacy service, called the integrated care clinical pharmacist. Older people confined to their own homes due to are known to be at risk of...
At Northwestern Medical Group in Chicago, a patient-centered transitional care intervention serving patients with complex health needs that lack a usual source of care was found to reduce the...
This resource describes a randomized controlled trial to evaluate the effects of a case management intervention called V1SAGES (Vulnerable Patients in Primary Care: Nurse Case Management and Self...