Resources

Cityblock Health provides care to populations with high rates of social, behavioral, and health risk factors, many of whom are at higher risk for complications from COVID-19. Cityblock developed a...
Medicaid health homes were created by the Affordable Care Act to improve care for Medicaid enrollees with complex behavioral and physical health needs. Health homes that target behavioral health...
Complex care programs across the country use varied criteria to identify people with complex health and social needs and measure the effectiveness of subsequent interventions. Greater standardization...
In this blog post, Cambridge Health Alliance, a public ambulatory care and hospital system in the Boston area, details their proactive approach to initiating goals of care conversations with high-risk patients in their respiratory clinic.
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...