Features David Labby, MD, health strategy advisor for Health Share of Oregon, who provides insights on the recently released report on Camden Coalition's randomized controlled trial on the Camden Core Model.

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.

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.

Caroline Morgan Berchuck, MD, describes a promising new complex care hospitalist model that aims to address this fragmentation and support people with complex needs in realizing better health outcomes.

Dr. Mark Prather, emergency physician and founder of Dispatch Health, shares how his organization provides on-demand home visits in 10 metropolitan areas and provided nearly visits to nearly 100,000 visits to patients last year.

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.

A new care delivery model of providing hospital-level services in the home (sometimes referred to as “home hospitalization” or “hospital at home”) has been launching with pilots at a number of health systems nationally.

The Program of All-Inclusive Care for the Elderly provides comprehensive, compassionate medical care and long-term services and supports to older adults with persistent complex needs who are eligible for nursing home care. Yet, PACE reaches less than two percent of those who could benefit from its services.

The program, known as Community Aging in Place — Advancing Better Living for Elders (CAPABLE), is a client-directed home-based intervention to increase mobility, functionality, and capacity to “age in place” for older adults.

Effective complex care means first understanding the individual and the challenges they face in their day-to-day lives. Here are two stories of patients in the CareMore Touch program for people with institutional special needs.

Four key interventions are essential to create an age-friendly system of care. If care providers consistently do these four things for every older adult, every time, across care settings, we believe we will save lives and avoid harm.

Shares insights and guidance on how to use findings from a recently released report from the National Academy of Medicine, which explores the key attributes of patients with complex needs and how to improve care for this patient population.