Resources

Special Needs Plans (SNPs) are a type of Medicare Advantage (MA) plan for individuals with special needs. This can mean an institutionalized individual (i.e., someone who lives in nursing home), a dually eligible individual (i.e., eligible for both Medicare and Medicaid), or an individual with a severe or disabling chronic condition.
This resource is a toolkit to help payers and providers understand how home-based primary care (HBPC) improves quality and reduces costs for seriously ill and home-limited older adults. HBPC providers...
This resource identifies challenges faced by older adults from racial and ethnic minorities, and proposes several strategies to address them. Older adults from racial and ethnic minorities face...
This resource provides an example of an approach to caring for different subpopulations of people with dementia. UCLA Health adopted a structure that identifies people living with dementia, then...
Evidence is mounting about the importance of robust primary care in achieving the Triple Aim of advancing quality of care, reducing costs, and improving the patient experience. Primary care initiatives across the country have shown that enhancing primary care can coordinate service delivery to the benefit of both patients and clinicians. In Medicare accountable care organizations (ACOs), primary care transformation has been foundational for shifting to a team-based approach that reaps benefits for patients, providers, and payers.
The individual characteristic that contributes most to complex care needs is the inability to function in activities of daily living (ADLs), such as eating, bathing, and dressing. The winners in population health management will be the health plans and providers that figure out how to identify individuals with ADL impairment and address their needs with comprehensive care management and targeted non-medical services.
This resource describes a randomized controlled trial to evaluate the effects of a case management intervention called V1SAGES (Vulnerable Patients in Primary Care: Nurse Case Management and Self...
This resource describes an effort to apply a learning health systems approach to reducing ED utilization. A learning health system focuses on improving people’s health at scale through continuous...
This resource is a toolkit highlighting innovative care coordination strategies used by Medicare ACOs. ACOs use a variety of methods to coordinate and manage the care of their populations, including...
This resource is a toolkit for identifying patients with various physical, functional, emotional, social, and spiritual needs. Patients and families living with serious illness have a range of needs...
This resource is a study evaluating an alternative in-hospital assessment to determine the need for continuing care after discharge. In the UK, a long and complicated Continuing Health Care (CHC)...
Although senior living organizations are primarily oriented toward housing and hospitality, there are many reasons they provide a great platform for value-based care.