Case Managers for High-Risk, High-Cost Patients as Agents and Street-Level Bureaucrats How to improve the cost benefits of case management. Peer-Reviewed Article August 2017
Persistence and Drivers of High-Cost Status Among Dual-Eligible Medicare and Medicaid Beneficiaries Analyzes the largest drivers of high costs among persistently high-cost Medicare-Medicaid beneficiaries, and finds most spending related to long-term care. Peer-Reviewed Article October 2018
Academic Medical Centers and High-Need, High-Cost Patients: A Call to Action This resource describes how academic medical centers can reshape the health system for patients with complex needs. Peer-Reviewed Article November 2018
The ROI Calculator for Partnerships to Address the Social Determinants of Health A web-based financial tool that helps navigate partnerships between health care organizations and social service organizations. Implementation Tool August 2018
Care Management Contracting for Complex Populations: Best Practices and Tools This resource offers guidance on contracting for populations with complex needs. Implementation Tool July 2018
Medicaid Managed Care Best Practices Compendium This resource collects the most innovative initiatives in Medicaid managed care that emerge each year. Brief/Report January 2017
Investing in Social Services as a Core Strategy for Healthcare Organizations: Developing the Business Case This resource explains how to invest in social services as a business strategy. Implementation Tool March 2018
The CHRONIC Care Act of 2018: Advancing Care for Adults with Complex Needs A brief summarizes what you need to know about the new Chronic Care Act. Brief/Report March 2018
Compendium of Five Case Studies: Lessons for Interprofessional Teamwork The VA shares lessons on workforce learning and development. Brief/Report September 2017
Accountable Care Atlas: A Development Guide for Competency Implementation This resources describes the competencies organizations need to transition to value-based payment. Implementation Tool November 2017
Competing Health Care Systems and Complex Patients: An Inter-Professional Collaboration This paper describes competing health care systems can collaborate to improve care for overlapping patient populations. Peer-Reviewed Article June 2017
Complex Care Models to Achieve Accountable Care Readiness: Lessons from Two Community Hospitals Case studies of two community hospitals show how to advance accountable care. Case Example March 2018
Disability-Competent Care Self-Assessment Tool How disability-competent is your organization? Implementation Tool October 2017
Nursing Student Coaches for Emergency Department Super Utilizers Nursing students successfully coach patients with complex needs to avoid ED use. Peer-Reviewed Article January 2017
Diffusion of Community Health Workers Within Medicaid Managed Care: A Strategy to Address Social Determinants of Health New Mexico’s model to deploy community health workers is now replicated in 12 states. Case Example July 2017
Evaluation of the Medicaid Health Home Option for Beneficiaries with Chronic Conditions: Annual Report - Year Three This report presents the findings from the evaluation of Medicaid health homes, created as part of the Affordable Care Act. Brief/Report July 2015
Complex Care Program Development: A New Framework for Design and Evaluation A new framework outlines four steps to develop care management programs. Brief/Report March 2017
Development of a Care Guidance Index Based on What Matters to Patients The What Matters Index measures quality of life for people with chronic conditions. Peer-Reviewed Article January 2018
Effective Care for High-Need Patients: Opportunities for Improving Value, Outcomes and Health The National Academy of Medicine offers a synthesis of the evidence for improving care for high-needs patients. Brief/Report June 2017
Bridging the Silos of Service Delivery for High-Need, High-Cost Individuals A study of five programs identified key factors that support collaboration among community-based health and social services. Peer-Reviewed Article March 2016