Resources

A majority of mature accountable care organizations (ACOs) segment their high-need, high-cost (HNHC) population into smaller subgroups to better identify those with similar needs, employing a range of...
Approximately one in three Medicare beneficiaries is enrolled in a Medicare Advantage (MA) plan, and more than one third of these MA enrollees are classified as high need based on their chronic...
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...
This resource describes a new model that moves high-need patients out of the emergency department and into a network of social supports. Regional One Health, a large health system in Tennessee, has...
This resource describes the Great Plains Senior Services Collaborative, an initiative to improve health and quality of life for rural seniors. Populations of rural seniors face significant challenges...
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...
Based on a review of the evidence, the Quick Reference Guide to Promising Care Models offers summary information on 28 programs for adults with complex needs, specifically: Target population and...
This resource describes a promising new hospitalist model for inpatient treatment of complex care patients. In July 2016, Commonwealth Care Alliance and Boston Medical Center created a hospitalist...
This resource describes recent changes in Medicare Advantage (MA) and their implications for plans. The Centers for Medicare and Medicaid Services (CMS) has recently reinterpreted several key aspects...