People with complex health and social needs frequently encounter a fragmented healthcare system and experience a lack of continuity of care. In this video series, 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.
Dispatch Health: Reducing Avoidable Emergency Department Use Through On-Demand Acute Care Delivered to Patients in Their Homes
Dr. Mark Prather, board-certified emergency physician and founder of Dispatch Health, speaks to Rob Mechanic of the Institute for Accountable Care about 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.
Effect of the Serious Illness Care Program in Outpatient Oncology: A Cluster Randomized Clinical Trial
Rachelle Bernacki, MD, MS, talks about the Serious Illness Care Program at Ariadne Labs. Rachelle discusses developing, implementing, and scaling the Serious Illness Care Program as well as a few surprises and challenges she encountered in the development of this program.
Outcomes of a Citywide Campaign to Reduce Medicaid Hospital Readmissions with Connection to Primary Care Within 7 Days of Hospital Discharge
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 has more significant health and functional support needs than either Medicaid-only or Medicare-only populations. At the same time, individuals who are dually eligible face significant challenges in receiving well-coordinated care that is aligned with their needs.
Outpatient Complex Case Management: Health System-Tailored Risk Stratification Taxonomy to Identify High-Cost, High-Need Patients