Global budgets for hospitals reduced expenditures and utilization for some Medicare subpopulations with complex health and social needs, yet disparities existed for some subgroups.
Using segmentation to address clinical and social needs for Medicaid patients with complex needs and costly utilization can improve the effectiveness of complex care programs.
Describes electronic health record system functionality that automatically identifies patients likely to need technical assistance prior to telehealth visits.
Trust, flexible funding, cross-sector support, sustainability, and an explicit focus on structural racism are identified as key components of effective community engagement to advance health equity.
Case study of interdisciplinary primary care program for high-risk patients based at an academic health system offers lessons on program design and implementation.
Offers practical recommendations to improve telemedicine interventions to be more equitable for diverse populations, particularly those with low incomes.
Use of hospital readmission rates to measure quality may be unfair for some accountable care organizations and safety-net providers, since members with complex medical and social needs are a main driver of these rates.
Primary care and alternative payment models that reduce emergency department use and increase access to care for high-need populations share core components for success.
Home-based intensive care model for Medicaid and dually eligible enrollees with complex needs led to positive health outcomes and reduced acute care spending, particularly for individuals with a behavioral health diagnosis.
Use of machine learning clustering algorithms revealed 30 distinct subgroups of patients among high-risk veterans, indicating a need for tailored approaches to health care.
Discusses the benefits and challenges of tele-social care and offers practical tips for providers administering telehealth services for social care activities.
Suggests that community-based organizations are responding to Medicaid redesign efforts that prioritize social determinants of health by adopting practices similar to health care organizations.