This resource is a Disability-Competent Care Self-Assessment Tool.

This resource describes strategies that health care organizations and plans can use to provide care for patients with serious illness.


This resource proposes a Serious Illness Program Design and Implementation Framework (SIP Framework) to guide the development of programs for people with serious illness.

This resource examines the impact of participation in a Pioneer ACO and its care management program on emergency department (ED) visits, hospitalizations, and Medicare spending.


This resource describes the Complex Care Map (CCM ©), a tool that addresses fragmentation in the health system and helps providers understand the patient’s story.

This resource describes the Super Utilizer Project, a collaboration between an integrated health care organization and a baccalaureate school of nursing.


​​​​This resource describes a program in New Mexico that employs community health workers (CHWs) to address social determinants of health, as well as how that program was implemented and spread.

This resource contains profiles of nearly a hundred programs that target complex patients across 36 states and territories, including Puerto Rico and Washington, DC.


This resource proposes a framework to help guide the development of programs for populations with complex needs.