Resources

Understanding where and how high-risk patients receive care can inform efforts to improve care for this population. This study observed care patterns for more than 350,000 high-risk patients within...
IMPaCT is a standardized community health worker (CHW) intervention for high-risk patients that has been previously evaluated in three randomized clinical trials across various clinical settings and...
While community health worker (CHW) programs that serve low-income populations have demonstrated reductions in preventable acute care utilization, these programs often have limited funding. Developing...
Accountable care organizations (ACOs) have shown promise in improving care for individuals with chronic conditions who also have coexisting mental health conditions, in part by incentivizing hospitals...
Medicaid health homes were created by the Affordable Care Act to improve care for Medicaid enrollees with complex behavioral and physical health needs. Health homes that target behavioral health...
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 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 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...