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...
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...
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...
This study examined five programs that serve patients with complex needs through medical and non-medical services. Authors created a framework to illustrate the foundational factors that encourage...
This resource identifies and describes person-centered preferences that can inform approaches to advanced illness care. It also highlights exemplars of innovative programs that are trying new methods...
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...