Resources

This resource is a Disability-Competent Care Self-Assessment Tool. It was developed to help health plans and health systems evaluate their own ability to meet the needs of adults with functional...
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 examines the experience of providers with the Medicaid health home option, a provision of the Affordable Care Act. The health home model focuses on providing whole-person care to high...
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 examines Medicaid payment reform strategies for populations who receive LTSS. It includes case studies of state programs in Tennessee, Minnesota, and Arizona. A growing number of states...
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...
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 report recommends policy changes so that Medicare can pay for non-medical supports and services, such as meal delivery, transportation, and case management, to improve outcomes and lower costs...
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...