Identifying and Designing the Right Care Management Program: Insights from ACOs
Four care management models for ACOs.
Implementation Tool
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Re-envisioning Care for People with Involved Disabilities
Video series details how health systems can redesign primary care, including through home-based primary care programs, to better meet the needs of people with disabilities.
Implementation Tool
Health Care Transformation Task Force Value Partnership Evaluation Tool
A tool for assessing readiness for value-based partnerships.
Implementation Tool
Quick Reference Guide to Promising Care Models
This resource is an updated quick reference guide to promising models for people with complex needs.
Brief/Report
Outpatient Complex Case Management: Health System-Tailored Risk Stratification Taxonomy to Identify High-Cost, High-Need Patients
Maximizing the impact of outpatient complex case management.
Peer-Reviewed Article
Impact of a Complex Chronic Care Patient Case Conference on Quality and Utilization
The case conference approach to caring for complex patients.
Peer-Reviewed Article
Systematic Review of High-Cost Patients’ Characteristics and Healthcare Utilisation
An international analysis of high-cost patients.
Peer-Reviewed Article
Engaging High-Need Patients in Intensive Outpatient Programs: A Qualitative Synthesis of Engagement Strategies
Overcoming barriers to patient engagement.
Peer-Reviewed Article
How ACOs Are Caring for People with Complex Needs
An analysis of the National Survey of ACOs
Brief/Report
Interventions for Frequently Hospitalized Patients and Their Effect on Outcomes: A Systematic Review
Mixed evidence for efforts to reduce rehospitalizations.
Peer-Reviewed Article
Blueprint for Complex Care: Advancing the Field of Care for Individuals with Complex Health and Social Needs
This resource outlines the current state of complex care and recommendations for the future.
Implementation Tool
Going Beyond Clinical Care to Reduce Health Care Spending
A regional approach to health care transformation.
Peer-Reviewed Article
A New Hospitalist Model for Managing High-Cost, High-Need Patients
A hospitalist model for complex care.
Case Example
Impact of Primary Care Intensive Management on High-Risk Veterans’ Costs and Utilization
Supplementing primary care with team-based management.
Peer-Reviewed Article
Aging Gracefully: The PACE Approach to Caring for Frail Elders in the Community
Reviews lessons from the Program of All-Inclusive Care for the Elderly on serving high-need populations in community settings.
Case Example
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
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
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
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