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.

Allison Hamblin, MSPH, Senior Vice President at the Center for Health Care Strategies, explains how she and her team developed the map.