Resources

Many older adults in the United States experience social isolation and loneliness, which are associated with increased risks for premature mortality, dementia, and other poor health outcomes. Since...
How can health care systems across the nation effectively address social needs? An expert committee created by the National Academies of Sciences, Engineering, and Medicine (NASEM) sought to address...
While Medicare Advantage (MA) plans have new flexibility to target and cover supplemental benefits that address health-related social needs, few plans provided these types of benefits in 2019...
Developing authentic healing relationships is critical to applying interventions that fully support patients in achieving their goals. The Camden Coalition’s patient engagement framework, COACH, focuses on building these relationships and empowering patients to take full control of their health. This practical play outlines how to use the COACH model and offers tips to providers who wish to enhance patient engagement. DOWNLOAD AS A PDF »
Mapping community resources is a good starting point for developing the system of care needed to interrupt the cycle of hospitalization and emergency department use and create a pathway to health for patients with complex needs. Effective complex care models rest on a foundation of services and supports that go beyond the traditional reach of the health care system. Community asset mapping offers a practical framework for locating and cataloguing a full array of services and for identifying critical care gaps and potential partners. The goal of this play is to help you get started with asset...
In an environment where social determinants are playing more of a role in conversations about improving health outcomes, it is critical for the health care and social sectors (which often take the form of local community-based organizations, referred to as CBOs) to build mutually beneficial partnerships. This play outlines steps to help health systems and CBOs build relationships that draw on each other’s strengths, put patients first, and support ecosystem development in local communities. DOWNLOAD AS A PDF »
Access to a health care data-sharing platform can help social service providers better understand and address issues that lie at the intersection of their clients’ social and medical wellbeing. It can: (1) provide insight into relevant details of the medical situation that their client is facing; (2) help the social service organization identify clinicians who may be valuable partners in the individual’s care; and (3) enable them to access documentation that can help them better advocate for the client. The goal of this play is to help health systems provide access to health-related data to...
Transitional care programs — where a multidisciplinary team comprehensively assesses a patient’s medical and psychosocial needs, addresses modifiable barriers, and links them to primary care — can help address critical gaps in care for people with complex needs moving between locations of care, such as from hospital to home. These programs vary widely, both in terms of what services they provide, and whether services are delivered before hospital discharge, after discharge, or as part of a “bridging” intervention with both pre- and post-discharge components. A comparative effectiveness trial...
Family caregivers play a foundational role in the care of older adults with complex needs and disabilities from both a health care and economic standpoint. As the “baby boom” population ages, the need...
This resource analyzes preventable ED visits and identifies mechanisms for preventing them. To identify opportunities to prevent ED visits, Premier, a health care improvement company, analyzed nearly...
This resource builds on the seminal Home Alone study, the first national examination at how family caregivers manage medical and nursing tasks. Major findings of this new study include: Today’s...
This resource describes the findings from a symposium called “The Dual Imperative: What’s Next for Medicare-Medicaid Enrollees,” which brought together policymakers, consumers, advocates, researchers...