Resources

By Rebecca Clark, Institute for Healthcare Improvement If you’ve seen how quickly a relatively mobile older adult can turn into a frail and bedbound patient — not because of a primary illness, but because of a lack of movement — then you can appreciate how dramatically different care is at Saint Joseph Mercy Health System in southeast Michigan, and Anne Arundel Medical Center in Annapolis, Maryland. In both hospitals, a plan for mobility is developed for each patient and implemented when appropriate. Both Saint Joseph Mercy and Anne Arundel are organizations taking part in the Age-Friendly...
This resource reports on a randomized clinical trial assessing whether CHWs can effectively improve chronic disease outcomes. A large body of literature indicates that CHWs can be effective, but...
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.
By Corey Waller, Better Care Playbook Faculty and Principal at Health Management Associates I currently do some work as a locum tenens physician in the emergency department, filling in during staff shortages. In this capacity, I get to work in a few different hospital systems around the country. No matter which one I go to, I can count on the fundamental aspects of basic cardiac care to be delineated no matter where I am. Here’s the pathway: If a patient shows up to their primary care doctor and complains about chest pain, the provider will assess her with an EKG to determine if she’s having a...
This resource provides a roadmap for health plans providing complex chronic care to improve quality and their Medical Loss Ratio (MLR), a basic financial measurement used in the Affordable Care Act to...
Substance abuse disorder, commonly called addiction, is a treatable chronic disease that is a significant contributor to health care utilization and poor health outcomes. It’s estimated that up to 60 percent of patients in U.S. Level 1 Trauma Centers meet the criteria for a substance use disorder. Inpatient treatment for substance use disorder can improve recovery time and decrease length of stay, escalations of behavior, and 30-day readmissions. But few hospitals have a service line for these patients that goes from hospital admission, including through the emergency department, to discharge...
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.
This resource collects the most innovative initiatives in Medicaid managed care that emerge each year. Health plans submit their best practices for consideration of inclusion in this exclusive...
This resource is a guide for payer and provider organizations to invest in social determinants of health (SDOH) and integrate them into their core business model. Few health care organizations have...
Throughout the country, efforts are increasingly emerging to integrate social services into health care systems. This resource classifies new initiatives, identifies common challenges, and proposes...