Recommended set of evidence-based measures for high-quality care for patients with complex needs based on systematic review of relevant measures.

Medicare beneficiaries with dementia, especially Black and Hispanic patients, often receive poor quality end-of-life care.

While the Medicare hospice benefit has historically been designed to meet the needs of patients with cancer, people with dementia and their caregivers experience better outcomes when enrolled in hospice.

Summarizes research on the prevalence of social screening in health care settings, validity of social screening tools, and patient and provider perspectives on social screening.

Analytical approach for randomized controlled trials may be valuable for understanding the impact of complex care interventions and the subpopulations that may benefit from them.

With the steep increase in use of telehealth and video visits in the last few years, the reliance on technology-enabled medicine may heighten disparities in health care access.

Community-based care management programs for patients with complex health and social needs have the potential to reduce hospitalizations and inpatient costs.

This guide describes key strategies for health plans, accountable care organizations, and health systems to improve care for people with serious illness.

Describes the core elements and evidence base behind a home- and community-based palliative care model that was designed by stakeholders to support the health needs of people with serious illness.

These resources can help nurses educate and support family caregivers in performing complex medical tasks for their family members at home.

Explored how complex care stakeholders can incorporate a multi-factor approach to measure and demonstrate the value of complex care programs for diverse stakeholders.

Differing patterns of care utilization and mortality outcomes within subgroups of a complex patient population can help inform more targeted care interventions.

Home-based palliative care providers explore key facilitators and barriers to effectively delivering care within a value-based payment environment.

Segmentation framework with publicly available code files identifies specific and actionable patient cohorts with complex needs.

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.

Will look at the provider and payer relationship and discuss how successful partnerships between these two stakeholders can create sustainable and efficacious home and community based palliative care programs.

Home-based palliative care program implemented within an accountable care organization created cost savings through reduced hospital admissions and increased hospice length of stay.

This toolkit can support health care organizations in creating the business case for complex care programs.

Advance care planning more than one month prior to death is associated with decreased acute care utilization at the end of life and in-hospital death for people with serious illness.

Analysis of 310 health systems showed gaps in opioid receipt between Black and white patients, especially on dosage, which may be related to racial bias among clinicians.