Kedar Mate, MD, Chief Innovation and Education Officer at the Institute for Healthcare Improvement, discusses opportunities to integrate social care into health care delivery, based on a recently released National Academies of Sciences, Engineering, and Medicine report.

Highlights how skilled nursing facilities are switching to the Patient Driven Payment Model — a payment system that removes therapy minutes as the basis for payment and enhances payment accuracy for services by making reimbursement dependent on a wide range of clinical characteristics.

Discusses, COACH, a new framework that Camden Coalition utilizes to build authentic relationships with patients and to increase patient engagement.

Explores the use of asset mapping to build stronger ecosystems of care, address the root causes of repeated hospital utilization, and improve care delivery for individuals with complex health and social needs.

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.