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.

Nearly 12 million individuals are enrolled in both Medicare and Medicaid. This “dually eligible” population 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.

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.

Andrew McClure of Senior Whole Health, a Magellan company, discusses his work around aligning quality measurement and improvement and offers insight on what drove the success of this partnership between medical group providers and this special needs health plan.

Describes the implications of Title III of the Bipartisan Budget Act of 2018, which containes a series of landmark provisions for advancing the integration of Medicare and Medicaid and for improving care for persons with complex chronic conditions.

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.

To achieve the quality and cost outcomes we seek, Medicare and Medicaid services must be coordinated through one unified plan. And in some cases, this is already happening.

Walks through some of the most common barriers to treating and referring patients with substance abuse disorder in the emergency department and how to address these challenges.

Looks at how the Keystone ACO partnership, serving residents of 41 primarily rural Pennsylvania counties as well as parts of New York, New Jersey and Maryland, is using community health workers to improve the quality and cultural competence of service delivery.

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 dialogue on caring for patients with complex needs has moved beyond a recognition that social factors like housing or nutrition have an outsize impact on health to practicalities. Now, health care providers are asking: what can we actually do to help?

Explores how complex care program leaders can make a case for the value of their programs to senior management, and how to initiate a conversation with payers on how funding these programs can be beneficial for both parties.

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.