Resources

The Massachusetts Health Policy Commission's Community Hospital Acceleration, Revitalization, and Transformation (CHART) investment program has engaged 25 community hospitals to advance readiness for...
This resource describes the findings of the International Experts Working Group on Patients with Complex Needs. The Commonwealth Fund established this group in 2014 to outline the components of a high...
This resource presents results from a systematic review of the international evidence on the costs, resource use, and cost-effectiveness of Clinical Nurse Specialist–led interventions for patients...
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 Serious Illness Program Design and Implementation Framework (SIP Framework) to guide the development of programs for people with serious illness. The process begins with...
This resource examines the impact of participation in a Pioneer ACO and its care management program on emergency department (ED) visits, hospitalizations, and Medicare spending. The care management...
This resource describes the Super Utilizer Project, a collaboration between an integrated health care organization and a baccalaureate school of nursing. The goal was to help patients with complex...
​​​​ This resource describes a program in New Mexico that employs community health workers (CHWs) to address social determinants of health, as well as how that program was implemented and spread. CHWs...
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 resource is the product of a collaborative assessment on strategies for better serving high-need patients convened by the National Academy of Medicine (NAM). Activities included workshops, a...