Person-centered care is of critical importance to the care of people with involved disabilities. This blog 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

In 2016, SMG began an initiative to integrate palliative care services into its primary care practices. However, after encountering challenges, SMG leaders chose to outsource palliative care to an external palliative care agency, Aspire Health. This blog post describes SMG’s experience and offers advice for other ACOs that are struggling to expand palliative care services and looking for a path forward. 

People with complex health and social needs frequently encounter a fragmented healthcare system and experience a lack of continuity of care. In this video series, 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, board-certified emergency physician and founder of Dispatch Health, speaks to Rob Mechanic of the Institute for Accountable Care about 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.

Rachelle Bernacki, MD, MS, talks about the Serious Illness Care Program at Ariadne Labs. Rachelle discusses developing, implementing, and scaling the Serious Illness Care Program as well as a few surprises and challenges she encountered in the development of this program.

What typically happens when a clinician meets a patient with complex care needs? Co-designing care is especially important when the care is for people with complex needs. Here are some tips for co-designing complex care management.

Nearly 12 million individuals are enrolled in both Medicare and Medicaid. This “dually eligible” population has more significant health and functional support needs than either Medicaid-only or Medicare-only populations. At the same time, individuals who are dually eligible face significant challenges in receiving well-coordinated care that is aligned with their needs.

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.

On Thursday, January 17, 2019 , the Playbook presented a webinar exploring how nurses can be integrated into complex care teams. This interactive online discussion provided opportunities to share ideas and ask questions. The panelists had expertise in both nursing and policy. 

For the past 20 years, the fundamentals of health care delivery have remained largely unchanged. Health plans rely on cost-shifting and utilization management to bend the cost curve, and doctors and hospitals accept lower prices in exchange for increased patient volumes.