Resources

The coronavirus pandemic intensified the already pressing need for the communication and symptom management expertise of palliative care specialists. Amid the surge of COVID-19 cases in New York City...
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...
This resource provides guidelines for implementing Special Supplemental Benefits for the Chronically Ill (SSBCI) in a manner that improves health care for chronically ill Medicare beneficiaries. The...
This resource provides a framework for understanding the nature and extent of integration in programs that integrate LTSS with medical care and behavioral health. This taxonomy is a standardized tool...
This resource used national survey data from physician practices and ACOs, paired with qualitative interviews, to learn about home visiting programs. ACO practices were more likely to report using...
This resource describes a national survey of ACOs about initiatives to address serious illness, as well as follow-up case studies. Only 8–21 percent of ACOs have widely implemented serious illness...
This resource describes an effort to apply a learning health systems approach to reducing ED utilization. A learning health system focuses on improving people’s health at scale through continuous...
This resource, the Partnership Evaluation Tool, is intended to help organizations assess readiness to engage in successful value-based partnerships. It can be used to assess potential partners or for...
This resource describes a study of the Johns Hopkins Community Health Partnership (J-CHiP), which was created as a regional approach to health care transformation in Baltimore, Maryland. J-CHiP...
This resource describes a randomized quality improvement trial that assessed whether augmenting usual primary care with team-based intensive management lowers utilization and costs for high-risk...
This resource describes the evolution of complex care management targeting strategies in Community Care of North Carolina’s (CCNC) work with the statewide non-dual Medicaid population, culminating in...
This tool is a calculator designed to assist community-based organizations and their health care partners in creating financial arrangements to fund social services for patients with complex needs. It...