Resources

Pathways for Integrating Social Care into Health Care Delivery: A Conversation with IHI’s Kedar Mate
To learn more about the recently released NASEM report on ways to integrate social care into health care delivery, the Better Care Playbook spoke with Kedar Mate, MD, Chief Innovation and Education Officer at the Institute for Healthcare Improvement, who served on the NASEM expert committee.
Cross-sector Collaboration for Vulnerable Populations Reduces Utilization and Strengthens Community Partnerships
Adventist Health Clear Lake, a health system in rural California, initiated a cross-sector collaboration between rural service providers and community agencies to more effectively address the needs of...
How Accountable Care Organizations Use Population Segmentation to Care for High-Need, High-Cost Patients
A majority of mature accountable care organizations (ACOs) segment their high-need, high-cost (HNHC) population into smaller subgroups to better identify those with similar needs, employing a range of...
Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation’s Health
How can health care systems across the nation effectively address social needs? An expert committee created by the National Academies of Sciences, Engineering, and Medicine (NASEM) sought to address...
Targeting High-Need Beneficiaries in Medicare Advantage: Opportunities to Address Medical and Social Needs
Approximately one in three Medicare beneficiaries is enrolled in a Medicare Advantage (MA) plan, and more than one third of these MA enrollees are classified as high need based on their chronic...
Using Self-Reported Data to Segment Older Adult Populations with Complex Care Needs
Incorporating patient self-reported data may allow health systems to more effectively identify specific groups of older adults with unique needs, thereby helping to inform the development of patient...
Coming Home and Staying There: Improving Care Transitions for Dually Eligible Beneficiaries
Improving transitions between care settings is critical to achieving positive health outcomes and enhanced quality of life, particularly for dually eligible beneficiaries navigating fragmented...
Are Medicare Advantage Plans Using New Supplemental Benefit Flexibility to Address Enrollees’ Health-Related Social Needs?
While Medicare Advantage (MA) plans have new flexibility to target and cover supplemental benefits that address health-related social needs, few plans provided these types of benefits in 2019...
Impact of Social Needs Navigation on Utilization Among High Utilizers in a Large Integrated Health System
A telephone-based social needs screening, referral, and navigation program that focused on patients with predicted high utilization within the Kaiser Permanente Southern California health system...
Impact of Supportive Housing on Substance Use-Related Health Care Utilization Among Homeless Persons who are Active Substance Users
Providing supportive housing for individuals experiencing homelessness who are identified as active substance users resulted in lower rates of SUD-related ED visits and hospitalizations compared to...
The New Post-Acute Care Management Solution for Complex Care Patients
This blog post highlights how skilled nursing facilities are switching over to the new Patient Driven Payment Model — a payment system that removes therapy minutes as the basis for payment and enhances payment accuracy for therapy, nursing, and ancillary services by making reimbursement dependent on a wide range of clinical characteristics.
Our COACHing Nature: The Camden Coalition’s Approach to Patient Engagement
This blog post highlights, COACH, a new framework that Camden Coalition utilizes to build authentic relationships with patients and to increase patient engagement.
Addressing Complex Care Needs Amid COVID-19

Resource Center: Addressing Complex Care Needs Amid COVID-19