Resources

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...
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...
Many older adults experience loneliness, which can lead to harmful impacts on mental as well as physical health. This literature review evaluated the effectiveness of published studies of...
When designing alternate payment models such as accountable care organizations (ACOs) to improve care for vulnerable populations, it is important to understand the impact that social determinants of...
While accountable care organizations (ACOs) offer promise for integrating social services into medical care, ACOs report significant barriers to successful integration. Using qualitative data from 22...
This resource collects the most innovative initiatives in Medicaid managed care that emerge each year. Health plans submit their best practices for consideration of inclusion in this exclusive...
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 describes strategies that health care organizations and plans can use to provide care for patients with serious illness. Palliative care — specialized care that focuses on addressing the...
This resource proposes a framework to help guide the development of programs for populations with complex needs. While medical drugs and devices go through a well-established, rigorous development...
To help improve care for people with multiple chronic conditions, the U.S. Department of Health and Human Services has developed the Multiple Chronic Conditions Education and Training Framework to...
This resource describes a care guidance index based on what matters to patients. Identifying a high-risk subgroup is a strategy for chronic care management. However, common methods of assessing risk...
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...