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...
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, 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 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...
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...