Resources

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...
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...
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...
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 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...
This resource describes how to develop and implement a model called the Intensive Outpatient Care Program, which uses a multidisciplinary team-based approach to address medical, behavioral, and social...
Based on a review of peer-reviewed and gray literature and interviews, this resource identified eight common attributes of many successful programs that provide better care for people with high needs...
This resource harvests the lessons learned from eight health care organizations that successfully developed programs for individuals with multiple chronic conditions and functional limitations. Ten...
This resource describes how to design, implement, and assess a “super-utilizer” (SU) program to address inappropriate care and reduce costs. SU programs provide person‐centered interventions to...