Resources

To improve health outcomes and reduce health care costs and utilization for people with complex needs, it is important to understand the underlying social and behavioral issues that may be driving...
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...
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...
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...
Individualized Management for Patient-Centered Targets (IMPaCT) is an intervention that employs community health workers to provide tailored social support to high-risk patients informed by patient...
Interventions targeting frequent emergency department (ED) users are increasingly common, but many are developed with limited understanding of this population’s comprehensive use of medical and social...
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...
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...
Project ECHO (Extension for Community Health Outcomes) virtually connects specialists with community-based providers to help improve patient care management. This evaluation of the ECHO Care pilot...
A randomized controlled trial found that the “Camden Core Model,” a short-term care management program for individuals with complex health and social needs and multiple recent hospital admissions, did...
Care coordination programs for individuals with multiple chronic conditions and unmet social needs can be operationally complex, but little research has been done on staff effort within these programs...
Adventist Health Clear Lake, a health system in rural California, initiated a cross-sector collaboration between rural service providers and community agencies to more effectively address the needs of...