Resources

Two notable randomized controlled trials of complex care management programs released earlier this year are spurring valuable discussions across the complex care field. The studies — based on...
Across the health care field, there is increasing recognition that in order to improve outcomes for patients with complex needs, health systems must understand the priorities of the communities they...
Improving transitions between care settings is critical to achieving positive health outcomes and enhanced quality of life, particularly for dually eligible beneficiaries navigating fragmented...
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...
It is widely recognized that good outcomes for patients with complex care needs are achievable when health care providers work locally and in tandem with community, government, and other partners...
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...
This resource describes four care management models that ACOs are using for individuals with complex needs. Care management programs can involve creating patient care plans, coordinating care across...
On Thursday, January 17, 2019 , the Playbook presented a webinar exploring how nurses can be integrated into complex care teams. They addressed the following questions: What is the future of...
On October 30, 2018, the Playbook convened a panel of leading complex care experts to address emerging best practices related to financing a complex care model. They addressed the following questions...