Resources

This resource provides an overview of a quality-improvement intervention focused on communication with patients with advanced cancer. High-quality conversations between clinicians and seriously ill...
Rachelle Bernacki, MD, MS, talks about the Serious Illness Care Program at Ariadne Labs. Rachelle discusses developing, implementing, and scaling the Serious Illness Care Program as well as a few surprises and challenges she encountered in the development of this program.
This resource describes the 7-Day Pledge program to reduce readmissions by increasing access to timely primary care appointments after hospitalization. Previous research suggests the important role of...
What typically happens when a clinician meets a patient with complex care needs? Co-designing care is especially important when the care is for people with complex needs. Here are some tips for co-designing complex care management.
This resource offers a variety of materials about “personas” for different segments of the high-need patient population. A persona helps depict the experiences, motivations, and goals of a group of...
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...
Nearly 12 million individuals are enrolled in both Medicare and Medicaid. This “dually eligible” population has more significant health and functional support needs than either Medicaid-only or Medicare-only populations. At the same time, individuals who are dually eligible face significant challenges in receiving well-coordinated care that is aligned with their needs.
This resource evaluates the impact of an interprofessional case conference approach in an academic primary care clinic. This study was conducted at a primary care clinic at a VA medical center. The...
This resource provides an evaluation of a health system’s outpatient complex case management (OPCM) program and examines whether OPCM lowers service utilization and health care costs. U.S. health...
This resource assesses the characteristics and health care utilization of high-cost patients and compares high-cost patients across payers and countries, based on a systematic review of studies in...
This resource describes the findings from a symposium called “The Dual Imperative: What’s Next for Medicare-Medicaid Enrollees,” which brought together policymakers, consumers, advocates, researchers...
Dr. Neglia and The Holston Medical Group have established a unique program that cares for acutely ill patients in an ambulatory setting even though their illnesses would qualify for an inpatient hospitalization.