Person-Centered Engagement at the Organizational Level

Contains strategies, tips, and case studies to assist health care stakeholders in building meaningful, person-centered engagement in their organizations.

Implementation Tool

January 2020

Building Authentic and Mutually Beneficial Partnerships with Complex Care Consumers

Outlines key steps health systems can take to build relationships with complex care consumers.

Play

January 2021

Supporting Family Caregivers Providing Complex Care

Includes promising practices, recommendations, vignettes, and other helpful tools to assist health systems in supporting family caregivers providing complex care.

Implementation Tool

November 2020

Aligning Social and Health Care Services: The Case of Community Care Connections

Demonstrates that a program assisting older adults with complex needs in navigating medical and social services may lower acute care utilization.

Peer-Reviewed Article

November 2020

The Preventive Effect of Housing First on Health Care Utilization and Costs Among Chronically Homeless Individuals

Demonstrates that Housing First programs and associated support services reduced health care related expenditures for the Massachusetts Medicaid program.

Brief/Report

December 2020

Lessons Learned from the Transition from Volume to Value

Describes factors that support health care organizations in transitioning from volume- to value-based payment.

Peer-Reviewed Article

October 2020

Identifying Populations with Complex Needs: Variation in Approaches Used to Select Complex Patient Populations

Summarizes different approaches and criteria that can be used to identify patients with complex needs for health system interventions.

Peer-Reviewed Article

September 2020

Medicare-Medicaid Integration: A Reference Guide to Emerging Evidence and Technical Assistance Tools

This reference guide summarizes a set of curated resources to help key stakeholders better understand both the needs of the dually eligible population and emerging evidence and practical approaches for advancing Medicare-Medicaid integration.

Implementation Tool

January 2021

What Works to Improve Care for Dual Eligible Individuals: An Evidence and Resource Review

Explores the Better Care Playbook's set of curated resources that can assist health plans, policymakers, and providers in understanding the evidence behind integrating care for individuals dually eligible for Medicare and Medicaid.

Blog

January 2021

Improving Care Coordination through Information Sharing

Leadership from the California Community Foundation and Southside Coalition of Community Health Centers explore their health information exchange pilot.

Blog

January 2021

How CommonSpirit’s Primary Care Clinics are Addressing Social Needs

CommonSpirit Health share their insights about the process of implementing social needs screening and integrating community health workers into care.

Blog

January 2021

A Team Approach with the Advanced Preventive Care Model

Health Quality Partners shares lessons for other organizations that may be interested in implementing complex care programs.

Blog

January 2021

Reimbursement for Evidence-Based Health Promotion Programs in the Community

Details funding opportunities and successful approaches in the adoption of evidence-based health promotion and disease prevention programs within community-based organizations.

Brief/Report

September 2020

Core Competencies for Frontline Complex Care Providers

Describes core competencies that convey the essential knowledge, skills, and attitudes of complex care practitioners and teams to improve care for people with complex needs.

Brief/Report

October 2020

A Systematic Review of Intensive Outpatient Care Programs for High-Need, High-Cost Patients

Demonstrates that intensive outpatient care programs show promise in reducing utilization and costs and improving patient outcomes for high-need, high-cost populations.

Peer-Reviewed Article

October 2020

Providing Non-Medical Supplemental Benefits in Medicare Advantage

Outlines practical steps for implementing flexible supplemental benefit offerings in Medicare Advantage plans.

Brief/Report

November 2020

COVID-19 Social Health Playbook

Presents tools and tips frontline care management staff to address high-risk patients’ unmet social health needs during the COVID-19 pandemic.

Implementation Tool

October 2020

Establishing Partnerships between Health Systems and Community-Based Organizations to Address Social Needs: First-Hand Perspectives from New York City

Features perspectives from leaders at Mount Sinai Health System and AIRnyc, a community-based organization that employs community health workers, on the opportunities and challenges of their partnership when it comes to addressing social needs.

Blog

December 2020

Better Care Playbook: Redesigned to Help You Better Redesign Care

Highlights key features of the newly redesigned Better Care Playbook.

Blog

December 2020

High-Cost Dual Eligibles' Service Use Demonstrates the Need for Supportive and Palliative Models of Care

Describes the needs of distinct subpopulations within the dually eligible population with highly complex needs, along with opportunities for tailored interventions that may reduce health care spending.

Peer-Reviewed Article

July 2017

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Content Types

Person-Centered Engagement at the Organizational Level

Building Authentic and Mutually Beneficial Partnerships with Complex Care Consumers

Supporting Family Caregivers Providing Complex Care

Aligning Social and Health Care Services: The Case of Community Care Connections

The Preventive Effect of Housing First on Health Care Utilization and Costs Among Chronically Homeless Individuals

Lessons Learned from the Transition from Volume to Value

Identifying Populations with Complex Needs: Variation in Approaches Used to Select Complex Patient Populations

Medicare-Medicaid Integration: A Reference Guide to Emerging Evidence and Technical Assistance Tools

What Works to Improve Care for Dual Eligible Individuals: An Evidence and Resource Review

Improving Care Coordination through Information Sharing

How CommonSpirit’s Primary Care Clinics are Addressing Social Needs

A Team Approach with the Advanced Preventive Care Model

Reimbursement for Evidence-Based Health Promotion Programs in the Community

Core Competencies for Frontline Complex Care Providers

A Systematic Review of Intensive Outpatient Care Programs for High-Need, High-Cost Patients

Providing Non-Medical Supplemental Benefits in Medicare Advantage

COVID-19 Social Health Playbook

Establishing Partnerships between Health Systems and Community-Based Organizations to Address Social Needs: First-Hand Perspectives from New York City

Better Care Playbook: Redesigned to Help You Better Redesign Care

High-Cost Dual Eligibles' Service Use Demonstrates the Need for Supportive and Palliative Models of Care