Resources

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 systematic review, which includes 27 studies across five models of care, evaluates the effectiveness of programs to improve care and lower cost for people with multiple chronic conditions or...
This resource offers a clinical vignette highlighting the challenges of caring for persons with complex needs, followed by descriptions of two approaches for managing these populations, and finally...
This resource provides a systematic review of transitional care interventions that reported hospital readmission as an outcome. Transitional care is a set of actions designed to ensure the...
The Commonwealth Fund surveyed patients with complex needs from June to September of 2016, and an analysis of the results reveals that the health care system is failing to meet these patients’ needs...
This resource explores the value of five different home visit program models. Home visits offer a way to reach high-risk, high-needs patients before a higher level of care is needed, thereby reducing...
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 summarizes a descriptive study of the Health Resilience Program (HRP) in Oregon, a program designed to address the needs of high-risk Medicaid and Medicare patients and reduce costs. In...
This resource analyzes nationwide 2014 ED data across 13 geographically dispersed US states. Findings include: For ED visits covered by Medicaid, high-need, high-cost patients were on average older...
This resource analyzes a number of specific care models that serve Medicare-only individuals and enumerates five main policy barriers and potential strategies to address these barriers. The specific...
This resource describes opportunities to use digital health products for high-need, high-cost populations. It summarizes the results of the Super-Utilizer Health Innovation Challenge, run by the...
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...