An interdisciplinary team approach can improve care coordination and reduce length of hospital stays for older adults with complex health and social needs.
Describes electronic health record system functionality that automatically identifies patients likely to need technical assistance prior to telehealth visits.
CAPABLE, a home-based care program that provides interdisciplinary services for older adults, leads to reductions in disability as well as cost savings.
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.
During the COVID-19 pandemic, Cityblock Health implemented a virtually integrated care management model to maintain continuity of care for patients with complex needs.
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 program provided by a community health and social worker reduces acute care use and improves care for older adults with complex health and social needs.
Toolkit details how hospitals and health systems can use patient race, ethnicity, and language data to advance health equity and eliminate disparities.
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.
The 4Ms approach developed for the Age-Friendly Health System model — what matters, medication, mentation, mobility — has a robust evidence base for providing quality care to older adults.
Discusses the benefits and challenges of tele-social care and offers practical tips for providers administering telehealth services for social care activities.