Resources

Although health care systems commonly refer individuals with unmet social needs to social service agencies, in some cases, these agencies may not have the capacity to provide adequate assistance. This...
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...
While high-cost patients include diverse subgroups with varying clinical and social needs, efforts to improve the efficiency of care and target interventions have been limited by the lack of knowledge...
Many older adults in the United States experience social isolation and loneliness, which are associated with increased risks for premature mortality, dementia, and other poor health outcomes. Since...
The causes of social isolation and loneliness in older adults, including their health, income, and place of residence, may impede their ability to participate in community-based social activities...
Two notable randomized controlled trials of complex care management programs released earlier this year are spurring valuable discussions across the complex care field. The studies — based on...
High-need, high-cost Medicaid patients enrolled in a 12-month complex care management program at CareMore Health in Memphis, Tennessee experienced reductions of 59 percent in inpatient utilization and...
Many different care management program models have been implemented for high-need, high-cost (HNHC) populations, with programs varying widely in their impact on patient outcomes and satisfaction and...
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...
ECHO Care is a complex care intervention pilot that integrated the Project ECHO model, which links primary care practitioners virtually with specialists, with outpatient intensivist teams (OITs) in...