Medicaid Managed Care Best Practices Compendium This resource collects the most innovative initiatives in Medicaid managed care that emerge each year. Brief/Report January 2017
Nursing Student Coaches for Emergency Department Super Utilizers Nursing students successfully coach patients with complex needs to avoid ED use. Peer-Reviewed Article January 2017
How High-Need Patients Experience Health Care in the United States This 2016 survey reveals that the health care system is failing people with complex needs Brief/Report December 2016
The Business Case for Community Paramedicine: Lessons from Commonwealth Care Alliance’s Pilot Program Cost considerations for the expansion of mobile integrated health care and community paramedicine programs. Case Example December 2016
Reduced Emergency Room and Hospital Utilization in Persons with Multiple Chronic Conditions and Disability Receiving Home-Based Primary Care People with multiple chronic conditions and disabilities enrolled in home-based primary care experienced persistent reduced acute care utilization. Peer-Reviewed Article October 2016
What Matters Most: Essential Attributes of a High-Quality System of Care for Adults with Complex Care Needs Experts describe how delivery systems can effectively serve adults with complex needs. Brief/Report September 2016
Delivery System Reform: Improving Care for Individuals Dually Eligible for Medicare and Medicaid Dual-eligible beneficiaries are often more sick, have greater functional and cognitive impairments, and require more care coordination. Brief/Report September 2016
Tailoring Complex Care Management, Coordination, and Integration for High-Need, High-Cost Patients Improving care for high-need, high-cost patients is a key lever to decrease national health spending. Brief/Report September 2016
Aging Gracefully: The PACE Approach to Caring for Frail Elders in the Community Reviews lessons from the Program of All-Inclusive Care for the Elderly on serving high-need populations in community settings. Case Example August 2016
The Hospital at Home Model: Bringing Hospital-Level Care to the Patient The program offers a lower-cost alternative to the hospital for patients who can be safely treated at home. Case Example August 2016
High-Need, High-Cost Patients: Who Are They and How Do They Use Health Care? There is considerable variation in use and spending among high-need adults, suggesting this population should be segmented into subgroups. Brief/Report August 2016
Payment to Promote Sustainability of Care Management Models for High-Need, High-Cost Patients Provider incentives must be based on Triple Aim outcomes. Brief/Report May 2016
Key Components for Successful LTSS Integration: Lessons from Five Exemplar Plans Successful long-term services and supports programs have a single point of accountability, such as a care manager. Brief/Report April 2016
Taxonomy of Long-Term Services and Supports Integration A standardized tool to assess where along a continuum a program lies with regard to components of integration. Implementation Tool April 2016
So Many Options, Where Do We Start? An Overview of the Care Transitions Literature A systemic review of transitional care interventions reporting hospital readmission Peer-Reviewed Article March 2016
Bridging the Silos of Service Delivery for High-Need, High-Cost Individuals A study of five programs identified key factors that support collaboration among community-based health and social services. Peer-Reviewed Article March 2016
Developing Care Management Programs to Serve High-Need, High-Cost Populations Care management programs should include processes for evaluating patient-reported outcomes. Brief/Report February 2016
Home-Based Primary Care Interventions Systematic review demonstrates the potential of home-based primary care interventions for improving heath, cost, and patient experience outcomes for adults with multiple chronic conditions and serious disabilities. Peer-Reviewed Article February 2016
The Health Resilience Program: A Program Assessment Health Resilience Specialists work with the patients to meet their personal health needs Case Example January 2016
How High-Need Patients Experience the Health Care System in Nine Countries The U.S. had the highest rate of cost-related access problems. Brief/Report January 2016