Resources

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...
The challenge of managing Medicare patients with multiple health conditions is familiar to most providers. According to recent data from the Centers for Medicare and Medicaid Services (CMS), two-thirds of Medicare patients have two or more chronic conditions. Establishing treatment guidelines for every condition and for every patient is challenging for a multitude of reasons. A recent study estimated that 37 percent of the average family physician’s time is spent on chronic care, with the balance on acute or preventive care. For Medicare patients, it may be even higher.
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...
New flexibility for Medicare Advantage (MA) program represents a major turning point in Medicare policy and an opportunity for health insurers and providers to work together in new and more productive ways.
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...
Family caregivers play a foundational role in the care of older adults with complex needs and disabilities from both a health care and economic standpoint. As the “baby boom” population ages, the need...
Family caregivers are a critical part of the home- and community-based workforce for people with serious illness. This is particularly the case for veterans, who are often sicker than the general...
This resource describes a study of five plans that integrate LTSS into care. The study examined differences in medical utilization by beneficiaries, compared to a population with a similar level of...
This study compared health services use and costs depending on whether the primary care provider was a physician, NP, or PA. NPs and PAs are taking a larger role in the primary care of medically...
This resource provides guidelines for implementing Special Supplemental Benefits for the Chronically Ill (SSBCI) in a manner that improves health care for chronically ill Medicare beneficiaries. The...