Resources

Palliative care improves quality of life for both the patient and the family. It is appropriate at any age and at any stage of illness, and it can be provided along with curative treatment. Palliative...
This blog post by David Labby, MD, PhD, health strategy advisor at Health Share of Oregon, outlines how the COVID-19 response presents key opportunities for health systems to build new relationships and approaches needed for a recovery-oriented approach to complex care.
This blog post highlights opportunities for MA plans to provide non-medical supplemental benefits during COVID-19 — including in-home supports, meal and grocery deliveries, home modifications, and transitional supports — to help Medicare beneficiaries shelter at home.
Although health care systems commonly refer individuals with unmet social needs to social service agencies, in some cases, these agencies may not have the capacity to provide adequate assistance. This...
Integrated primary care teams have demonstrated positive impacts on patient care, but less is known about the impact of including social workers on these teams. This study evaluated the addition of...
In this blog post, Melanie Bella, MBA, chief of new business and policy at Cityblock Health and former director of the Medicare-Medicaid Coordination Office at the Centers for Medicare & Medicaid Services, explores implications of the current moment to influence the future landscape for integrating Medicare and Medicaid services.
Whole Person Care (WPC) pilots, under California’s Medicaid Section 1115(a) waiver demonstration, integrate medical, behavioral health, and social needs services to improve the health and wellbeing of...
Health care organizations are increasingly partnering with Area Agencies on Aging (AAAs) to provide social needs support for older adults in the community who are identified with high health risks...
Effective patient-centered case management interventions can potentially improve health and social outcomes for individuals experiencing homelessness or housing instability. This literature review...
One Community Health has been providing innovative health care in a rural region of the Pacific Northwest for more than 30 years. When the COVID-19 pandemic struck, the health center partnered with OCHIN to rapidly transform its care delivery model, implementing new virtual care tools to safely and effectively serve vulnerable patients with complex needs through the pandemic and beyond.
To improve health outcomes and reduce health care costs and utilization for people with complex needs, it is important to understand the underlying social and behavioral issues that may be driving...
Engaging patients in shared decision-making requires providers to integrate patient-identified goals into patient-provider communications. This qualitative study explored how high-need, high-cost...