A new framework outlines four steps to develop care management programs.

Analysis of care models that serve Medicare-only individuals detailing policy barriers to providing uncovered services and supports and proposed strategies to address them.

This resource collects the most innovative initiatives in Medicaid managed care that emerge each year.

Nursing students successfully coach patients with complex needs to avoid ED use.

This 2016 survey reveals that the health care system is failing people with complex needs

Experts describe how delivery systems can effectively serve adults with complex needs.

The program offers a lower-cost alternative to the hospital for patients who can be safely treated at home.

Provider incentives must be based on Triple Aim outcomes.

A standardized tool to assess where along a continuum a program lies with regard to components of integration.

A systemic review of transitional care interventions reporting hospital readmission

A study of five programs identified key factors that support collaboration among community-based health and social services.

Systematic review demonstrates the potential of home-based primary care interventions for improving heath, cost, and patient experience outcomes for adults with multiple chronic conditions and serious disabilities.

Care management programs should include processes for evaluating patient-reported outcomes.

There are many promising strategies to segment individuals with complex needs. Here is one conceptual framework.

Health Resilience Specialists work with the patients to meet their personal health needs

Key opportunities include strengthening information technology connections across service providers.

Segmenting the high-cost population is the first step in matching appropriate care management strategies.

A three-pronged strategy can help manage care for Medicare beneficiaries.