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

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

Offers a practical framework for safety-net health systems to better identify and segment patients with complex needs, and tailor care models to meet their needs.

This case study highlights an accountable care organization’s home-based primary care program for homebound older adults, with early analysis of outcomes showing reduced acute care utilization.

Medicare patients with the top five percent in preventable utilization account for almost half of all avoidable Medicare costs.

Step-by-step guide with robust tools for health systems to apply the 4Ms framework to deliver age-friendly, evidence-based care for older adults.

Effective complex care measures vary widely and need to be standardized to better align the field of complex care.

The proportion of low-income, frail, and medically complex individuals enrolled in Medicare Advantage is increasing.

Analysis of expanded supplemental benefit adoption for Medicare Advantage enrollees

Accountable care organizations must address key funding, community partnership, and data sharing requirements to successfully integrate social services into medical care.

Demonstrating return-on-investment to advance effective business relationships between community-based organizations and health care partners.

How can a community-based organization demonstrate the two-way financial benefits of partnering with a health plan?

Among high-cost Medicare enrollees, those who are seriously ill, frail, and/or had a serious mental illness experience the most potentially preventable spending.

Randomized controlled trial of a care management intervention offers important lessons for the field of complex care.

Providing virtual case mentoring to outpatient care teams may reduce unnecessary hospital and emergency department visits for high-need, high-cost patients.

Connecting complex care teams with specialists through videoconferencing can increase their effectiveness in caring for high-need high-cost patients.

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

Assessing post-discharge needs.

Impact of social needs navigation program on future utilization of patients with prior high utilization.

A unique cross-sector partnership involving health care, police, and emergency services improved health care utilization in this rural health system pilot.