Resources

The Keystone ACO is a partnership between Geisinger, Evangelical Community Hospital, Wayne Memorial Hospital, and the Wright Center for Graduate Medical Education. It serves 73,000 Medicare beneficiaries in the Medicare Shared Savings Program (MSSP). Keystone ACO’s beneficiaries include residents of 41 primarily rural Pennsylvania counties as well as parts of New York, New Jersey and Maryland.
This play was produced by the Institute for Healthcare Improvement (IHI) and authored by Corey Waller, MD. Substance use disorder, commonly called addiction, is a treatable chronic disease that is a significant contributor to health care utilization and poor health outcomes in the United States. Even though it is estimated that up to 60 percent of patients in the US Level 1 Trauma Centers meet the criteria for a substance use disorder, few hospital emergency departments have a service line for these patients. This Play can help you treat substance use disorder in the emergency department as...
This resource reviews efforts of academic medical centers (AMCs) to improve care for patients with complex needs, and the opportunities for AMCs to contribute to better care throughout the health...
This resource describes the evolution of complex care management targeting strategies in Community Care of North Carolina’s (CCNC) work with the statewide non-dual Medicaid population, culminating in...
This resource assesses HealthChoices HealthConnections, an integration pilot program for Medicaid beneficiaries with SMI and co-occurring chronic conditions in three Pennsylvania counties. Better data...
One of the most pervasive challenges in our health care system is allowing people to optimize their independence and continue living at home as they age and develop more complex health and social needs. These individuals often need long-term services and supports (LTSS), and their number is increasing. It’s estimated that the population of Americans in need of LTSS will rise to 27 million by 2050.
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?
This tool is a calculator designed to assist community-based organizations and their health care partners in creating financial arrangements to fund social services for patients with complex needs. It...
This resource provides guidance for state leaders in establishing and advancing complex care programs. Since 2013, the National Governors Association Center for Best Practices (NGA Center) Health...
This resource examines three innovative models for treating patients with serious illness, developed by third-party firms that contract with Medicare Advantage plans. The financing structure of...
Caring for the complex chronically ill — a population that makes up about 5 percent of patients and nearly 50 percent of health care spending — is remarkably challenging. It’s also essential, as the United States transitions to a health care system that is driven by value.
This resource reviews best practices in care management contracting based on in-depth interviews with organizations that operate sustainable, effective programs for patients with complex needs. The...