Explores the tension between health systems and community-based organizations and discusses strategies for successfully navigating it.

Explores the Camden Coalition of Healthcare Providers’ Health Information Exchange, a web-based application that gives providers across health systems real-time access to medical information for patients with complex needs.

Our ability to effectively treat the growing number of individuals who live with multiple chronic diseases will remain compromised unless health systems explore innovative approaches.

New flexibility for Medicare Advantage program represents a major turning point in Medicare policy and an opportunity for health insurers and providers to work together in new and more productive ways.

For frail older adults with complex care needs, an inpatient hospital stay is destabilizing and often marks the beginning of a decline in functioning. For these older adults and their families, the post-hospital period is a risky, confusing, and stressful time.

The time constraints of the typical primary care practice often do not allow providers to take a comprehensive look at all of their patients’ needs. Enabling office staff to assist in this work, presents a tremendous opportunity to create patient-centered and comprehensive care plans.

From continued enrollment growth to expanded flexibility to offer non-medical supplemental benefits, Medicare Advantage plans are playing an increasingly important role in the lives of older adults.

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. 

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.

Rachelle Bernacki, MD, discusses developing, implementing, and scaling the Serious Illness Care Program at Ariadne Labs, including a few surprises and challenges from along the way.

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.