Understanding the values of patients with complex health and social needs can help providers improve care.

Person-centered integrated care models designed to respond to the priorities of people dually eligible for Medicare and Medicaid are more likely to increase and sustain enrollment.

An intervention supporting caregivers of adults with chronic medical and functional needs can generate cost savings and improve outcomes for Medicare Advantage enrollees and their caregivers.

Disparities in transitional care training for caregivers of older adults based on race or financial status demonstrate need for changes in discharge processes and strategies to address bias.

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.

Includes promising practices, recommendations, vignettes, and other helpful tools to assist health systems in supporting family caregivers providing complex care.

High-need, high-cost older adult patients detail their health care goals, which may inform provider efforts to effectively engage with and care for these patients and their family caregivers.

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

The patient priorities care approach, which aligns care with patient goals, leads to reductions in treatment burden and unwanted care.

Challenges and opportunities for older adults with multiple chronic conditions.

Family caregivers are an integral part of health care and the economy, and they need states’ support.

Includes national survey data on family caregivers and their experiences in managing complex medical and nursing tasks for their family members at home, as well as recommendations to improve the supports for family caregivers.

An in-depth overview of different personas.

Describes how a health system can adapt workflow, roles and responsibilities, and communication to engage family caregivers in care transitions and comply with CARE Act requirements.

Provides lessons on the function and impact of health plan Consumer Advisory Councils from Medicare-Medicaid Plans in capitated model demonstrations under the Financial Alignment Initiative.

Overcoming barriers to patient engagement.

The psychological benefits of case management.

Including caregivers in the discharge planning process reduces the risk of hospital readmission for older adults.

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

Federal policy changes have made PCC models of care more financially viable.