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.

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.