Strategies for Change—A Collaborative Journey to Transform Advanced Illness Care
Person-centered preferences can inform approaches to advanced illness care
Brief/Report
All Resources
Topics
Populations
Audiences
Content Types
State
Topics
Populations
Audiences
Content Types
State
Displaying 901 - 920 of 970
Reduced Emergency Room and Hospital Utilization in Persons with Multiple Chronic Conditions and Disability Receiving Home-Based Primary Care
People with multiple chronic conditions and disabilities enrolled in home-based primary care experienced persistent reduced acute care utilization.
Peer-Reviewed Article
Hennepin Health: A Care Delivery Paradigm for New Medicaid Beneficiaries
By closing gaps in care, a safety-net ACO has reduced medical costs for Medicaid patients with complex needs.
Case Example
New Models of Primary Care Workforce and Financing: Case Example #1: Stanford Coordinated Care
Stanford Coordinated Care provides university employees with complex health needs better care at a lower cost
Case Example
Guided Care: A Structured Approach to Providing Comprehensive Primary Care for Complex Patients
Guided Care is designed to strike a balance between telephone-based and interdisciplinary team-based care management programs.
Case Example
Home-Based Care Program Reduces Disability and Promotes Aging in Place
Difficulty with activities of daily living is a major cost driver in health care that is typically overlooked.
Peer-Reviewed Article
Tailoring Complex Care Management, Coordination, and Integration for High-Need, High-Cost Patients
Improving care for high-need, high-cost patients is a key lever to decrease national health spending.
Brief/Report
What Matters Most: Essential Attributes of a High-Quality System of Care for Adults with Complex Care Needs
Experts describe how delivery systems can effectively serve adults with complex needs.
Brief/Report
Delivery System Reform: Improving Care for Individuals Dually Eligible for Medicare and Medicaid
Dual-eligible beneficiaries are often more sick, have greater functional and cognitive impairments, and require more care coordination.
Brief/Report
A Systematic Review of Evidence for the Clubhouse Model of Psychosocial Rehabilitation
“Clubhouses” for people with serious mental illness are effective at promoting employment, reducing hospitalizations, and improving quality of life.
Peer-Reviewed Article
High-Need, High-Cost Patients: Who Are They and How Do They Use Health Care?
There is considerable variation in use and spending among high-need adults, suggesting this population should be segmented into subgroups.
Brief/Report
Aging Gracefully: The PACE Approach to Caring for Frail Elders in the Community
Reviews lessons from the Program of All-Inclusive Care for the Elderly on serving high-need populations in community settings.
Case Example
The Hospital at Home Model: Bringing Hospital-Level Care to the Patient
The program offers a lower-cost alternative to the hospital for patients who can be safely treated at home.
Case Example
Improving Population Health Management Strategies: Identifying Likely Users of Avoidable Costly Care
Assessing patients’ activation levels can help identify those at risk for poor health outcomes and utilization of avoidable, costly care.
Peer-Reviewed Article
The Core of Care Management: The Role of Authentic Relationships in Caring for Patients with Frequent Hospitalizations
This study links “authentic healing relationships” with patient motivation and active health management.
Peer-Reviewed Article
Health System Performance for the High-Need Patient: A Look at Access to Care and Patient Care Experiences
One in five high-need adults reported having an unmet medical need.
Brief/Report
Project ECHO’s Complex Care Initiative: Building Capacity to Help “Superutilizers”
Interdisciplinary teams provide support for Medicaid beneficiaries with mental illnesses, addictions, and other needs.
Case Example
Leveraging the Social Determinants of Health: What Works?
This literature review assesses the impact of social service interventions.
Peer-Reviewed Article
Bringing Primary Care Home: The Medical House Call Program at MedStar Washington Hospital Center
A home-based primary care program decreases costs and utilization for high-risk Medicare enrollees in Washington D.C.
Case Example
Person-Centered Care: The Business Case
Federal policy changes have made PCC models of care more financially viable.
Brief/Report