Resources

This resource describes and analyzes the different professional compositions of care management programs. Based on a national survey of clinicians caring for complex populations, nearly 40 percent of...
This resource provides a framework for understanding the nature and extent of integration in programs that integrate LTSS with medical care and behavioral health. This taxonomy is a standardized tool...
For frail older adults with complex care needs, an inpatient hospital stay is destabilizing and often marks the beginning of a decline in functioning. For these older adults and their families, the post-hospital period is a risky, confusing, and stressful time. Providers, payers, hospitals and health systems should look for ways to innovate their care delivery models and to manage and improve care for their patients.
This resource used national survey data from physician practices and ACOs, paired with qualitative interviews, to learn about home visiting programs. ACO practices were more likely to report using...
The time constraints of the typical primary care practice often do not allow providers to take a comprehensive look at all of their patients’ needs each year. Getting to the bottom of the checklist of preventive screenings and evaluating all ongoing chronic care needs simply takes time. Enabling office staff to assist in this work, under the direction of the supervising provider, presents a tremendous opportunity to create a patient-centered and comprehensive care plan that matches each patient’s unique needs and desires.
From continued enrollment growth to expanded flexibility to offer non-medical supplemental benefits, Medicare Advantage (MA) plans are playing an increasingly important role in the lives of older adults.
This resource describes and evaluates a new specialist pharmacy service, called the integrated care clinical pharmacist. Older people confined to their own homes due to are known to be at risk of...
This resource analyzes preventable ED visits and identifies mechanisms for preventing them. To identify opportunities to prevent ED visits, Premier, a health care improvement company, analyzed nearly...
This resource describes a national survey of ACOs about initiatives to address serious illness, as well as follow-up case studies. Only 8–21 percent of ACOs have widely implemented serious illness...
At Northwestern Medical Group in Chicago, a patient-centered transitional care intervention serving patients with complex health needs that lack a usual source of care was found to reduce the...
This resource highlights a variety of prevention-focused programs, initiatives and strategies (plays) focused on the opioid use epidemic. The resource describes 11 plays that are supported by evidence...
Christine Schaeffer, MD, medical director of Northwestern Medicine Transitional Care Clinic, describes the core components of its transitional care program. She also shares important considerations for health systems interested in implementing person-centered transitional care to address gaps in care and reduce costs.