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.

Provides an overview on Special Needs Plans (SNPs), a type of Medicare Advantage plan for individuals with special needs, the types of SNPs serving different populations, and how SNPs serving institutionalized individuals are unique.

Primary care initiatives have shown that enhancing primary care can coordinate service delivery to the benefit of both patients and clinicians. In Medicare ACOs, primary care transformation has been foundational for shifting to a team-based approach that reaps benefits for everyone involved.

The "winners" in population health management will be the health plans and providers that figure out how to identify individuals with activities of daily living impairment and address their needs with comprehensive care management and targeted non-medical services.

Although senior living organizations are primarily oriented toward housing and hospitality, there are many reasons they provide a great platform for value-based care.

HealthPartners of Minnesota, one of seven health plans in Minnesota’s state administered Minnesota Senior Health Options program, was highlighted in a recent report its unique dedication to improving transportation quality and convenience for its members, and the benefits of state supported Fully Integrated Dual Eligible Special Needs Plan.

As ACOs and MCOs develop value-based strategies for managing a complex care population, they should get to know the organizations in their market that offer housing and services aimed at this population.

Describes a series of video modules for health system leaders and clinicians that aims to reinvigorate the idea of person-centered care for those with complex health, social, and functional needs.

Describes Summit Medical Group’s experience integrating palliative care services and offers advice for other ACOs that are struggling to expand palliative care services and looking for a path forward.