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.

Congress recently passed a federal budget incorporating the CHRONIC Care Act that capitalizes on and grows early successes in many of these programs.

Many studies have highlighted the importance of effective interprofessional care teams to improve health outcomes for people with complex needs. But many programs do not take advantage of the special training of social workers to meet these needs on their primary health care teams.

It is relatively common knowledge among those that treat patients in a hospital setting that addiction-related issues are the number-one driver of extended length of stay, 30-day readmissions, and job-related dissatisfaction and burnout.

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.

Addiction is a chronic neurobiological disorder that is predictable, identifiable, and treatable. Dr. Corey Waller explains why evidence-based treatment needs to be in hospitals, primary care, stand-alone rehabs, and throughout the ecosystem of health care.

Organizations, whether non-profit or for-profit, need a return on investment in order to carry this work forward and continue to invest in innovation.

Discusses the Blueprint for Complex Care — a joint project of the National Center for Complex Health and Social Needs, the Center for Health Care Strategies, and the Institute for Healthcare Improvement — which is acting as a strategic plan for the emerging field of complex care.

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.

Most care delivery systems don’t proactively identify and meaningfully engage or support family caregivers in visits or care plans. Jennifer Wolff, PhD, a gerontologist and health services researcher shares how complex care programs can better engage families in care for patients.

How can you make the most of your community health needs assessments? Here are three tips to help you turn your assessments into action.

Christine Vogeli shares insights about how Partners HealthCare launched the Integrated Care Management Program, how the program is managed, and her advice for others getting started with care for people with complex needs.

Christine Vogeli, PhD, Director of Evaluation and Research at Partners HealthCare Center for Population Health, shares how their Integrated Care Management Program uses predictive analytics to identify patients to enroll.

Patients with complex needs are often described as the five percent of patients who account for 50 percent of health care spending. Behind that often cited statistic are the individuals who make up that population — all of whom have their own stories and needs.

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.

Marit Tanke, MD, PhD, a Commonwealth Fund Harkness Fellow, walks us through her research to analyze high-need, high-cost patients across four countries — including her methodology, how costly these patients are, who these patients are, and how they use health care.