Health Care Hotspotting — A Randomized, Controlled Trial Randomized controlled trial of a care management intervention offers important lessons for the field of complex care. Peer-Reviewed Article January 2020
ACO Serious Illness Care: Survey and Case Studies Depict Current Challenges and Future Opportunities How ACOs are addressing serious illness. Peer-Reviewed Article June 2019
Quick Reference Guide to Promising Care Models This resource is an updated quick reference guide to promising models for people with complex needs. Brief/Report February 2019
Ten Questions to Better Understand and Serve Your Complex Care Population California is asking Medicaid patients these ten questions about social and functional needs. Brief/Report April 2018
The CHRONIC Care Act of 2018: Advancing Care for Adults with Complex Needs A brief summarizes what you need to know about the new Chronic Care Act. Brief/Report March 2018
Complex Care Models to Achieve Accountable Care Readiness: Lessons from Two Community Hospitals Case studies of two community hospitals show how to advance accountable care. Case Example March 2018
Effective Care for High-Need Patients: Opportunities for Improving Value, Outcomes and Health The National Academy of Medicine offers a synthesis of the evidence for improving care for high-needs patients. Brief/Report June 2017
Integrating Health Care for High-Need Medicaid Beneficiaries With Serious Mental Illness and Chronic Physical Health Conditions at Managed Care, Provider, and Consumer Levels This resource describes the value of navigators for Medicaid beneficiaries with mental illness. Peer-Reviewed Article June 2017
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
Hennepin Health: A Care Delivery Paradigm for New Medicaid Beneficiaries By closing gaps in care, a safety-net ACO has reduced medical costs for Medicaid patients with complex needs. Case Example October 2016
Home-Based Care Program Reduces Disability and Promotes Aging in Place Difficulty with activities of daily living is a major cost driver in health care that is typically overlooked. Peer-Reviewed Article 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
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
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
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
Overview of Segmentation of High-Need, High-Cost Patient Population There are many promising strategies to segment individuals with complex needs. Here is one conceptual framework. Implementation Tool January 2016
Effective Management of High-Risk Medicare Populations A three-pronged strategy can help manage care for Medicare beneficiaries. Brief/Report September 2014
Use of Telemedicine Can Reduce Hospitalizations of Nursing Home Residents and Generate Savings for Medicare In nursing homes, replacing on-call physician services during off-hours with direct contact via telemedicine may reduce Medicare spending through fewer avoidable hospitalizations. Peer-Reviewed Article February 2014
Six Features of Medicare Coordinated Care Demonstration Programs that Cut Hospital Admissions A study showed that some programs reduced hospitalizations by 8 to 33 percent. Peer-Reviewed Article June 2012