CareMore: Improving Outcomes and Controlling Health Care Spending for High-Needs Patients CareMore’s business model identifies high-risk patients and surrounds them with coordinated services Case Example March 2017
Innovative Home Visit Models Associated with Reductions in Costs, Hospitalizations, and Emergency Department Use Home visits can reach patients with complex needs before a higher level of care is needed Peer-Reviewed Article March 2017
Complex Care Program Development: A New Framework for Design and Evaluation A new framework outlines four steps to develop care management programs. Brief/Report March 2017
The Business Case for Community Paramedicine: Lessons from Commonwealth Care Alliance’s Pilot Program Cost considerations for the expansion of mobile integrated health care and community paramedicine programs. Case Example December 2016
Intensive Outpatient Care Program Toolkit The staff position of care coordinator is crucial to success. Implementation Tool December 2016
The Care Transitions Intervention The Care Transitions Intervention was co-designed with patients and evaluated using randomized trials. Implementation Tool November 2016
Reduced Emergency Room and Hospital Utilization in Persons with Multiple Chronic Conditions and Disability Receiving Home-Based Primary Care People with multiple chronic conditions and disabilities enrolled in home-based primary care experienced persistent reduced acute care utilization. Peer-Reviewed Article October 2016
Guided Care: A Structured Approach to Providing Comprehensive Primary Care for Complex Patients Guided Care is designed to strike a balance between telephone-based and interdisciplinary team-based care management programs. Case Example October 2016
What Matters Most: Essential Attributes of a High-Quality System of Care for Adults with Complex Care Needs Experts describe how delivery systems can effectively serve adults with complex needs. Brief/Report September 2016
Home-Based Care Program Reduces Disability and Promotes Aging in Place Difficulty with activities of daily living is a major cost driver in health care that is typically overlooked. Peer-Reviewed Article September 2016
Aging Gracefully: The PACE Approach to Caring for Frail Elders in the Community Reviews lessons from the Program of All-Inclusive Care for the Elderly on serving high-need populations in community settings. Case Example August 2016
The Hospital at Home Model: Bringing Hospital-Level Care to the Patient The program offers a lower-cost alternative to the hospital for patients who can be safely treated at home. Case Example August 2016
Bringing Primary Care Home: The Medical House Call Program at MedStar Washington Hospital Center A home-based primary care program decreases costs and utilization for high-risk Medicare enrollees in Washington D.C. Case Example July 2016
So Many Options, Where Do We Start? An Overview of the Care Transitions Literature A systemic review of transitional care interventions reporting hospital readmission Peer-Reviewed Article March 2016
Developing Care Management Programs to Serve High-Need, High-Cost Populations Care management programs should include processes for evaluating patient-reported outcomes. Brief/Report February 2016
Home-Based Primary Care Interventions 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. Peer-Reviewed Article February 2016
House Calls: California Program For Homebound Patients Reduces Monthly Spending, Delivers Meaningful Care A novel approach to home visiting delivers cost reduction and better care Peer-Reviewed Article January 2016
The Health Resilience Program: A Program Assessment Health Resilience Specialists work with the patients to meet their personal health needs Case Example January 2016
High-Intensity Telemedicine Decreases Emergency Department Use for Ambulatory Care Sensitive Conditions by Older Adult Senior Living Community Residents Telemedicine may expand access to acute illness care and reduce emergency department visits for older adults. Peer-Reviewed Article December 2015
Attributes Common to Programs That Successfully Treat High-Need, High-Cost Individuals Targeting is important, even within the high-need patients enrolled in the program. Peer-Reviewed Article November 2015