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...
Integrated primary care teams have demonstrated positive impacts on patient care, but less is known about the impact of including social workers on these teams. This study evaluated the addition of...
Whole Person Care (WPC) pilots, under California’s Medicaid Section 1115(a) waiver demonstration, integrate medical, behavioral health, and social needs services to improve the health and wellbeing of...
Effective patient-centered case management interventions can potentially improve health and social outcomes for individuals experiencing homelessness or housing instability. This literature review...
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...
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...
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...
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...
When designing alternate payment models such as accountable care organizations (ACOs) to improve care for vulnerable populations, it is important to understand the impact that social determinants of...
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...