Taxonomy of Long-Term Services and Supports Integration A standardized tool to assess where along a continuum a program lies with regard to components of integration. Implementation Tool April 2016
Home-Based Primary Care Resources: A Toolkit for Health Partners This toolkit details the benefits of home-based primary care to help providers demonstrate the need for these programs. Implementation Tool June 2019
Towards a Learning Health System to Reduce Emergency Department Visits at a Population Level Predictive modeling to reduce ED utilization. Peer-Reviewed Article December 2018
Case Management in Primary Care for Frequent Users of Health Care Services: A Mixed Methods Study The psychological benefits of case management. Peer-Reviewed Article May 2018
A case study exploring the effectiveness of an innovative “5Q Care Test” to determine whether patients with complex needs require health or social care Assessing post-discharge needs. Peer-Reviewed Article November 2019
Experiences of community-dwelling older adults living with multiple chronic conditions: a qualitative study Challenges and opportunities for older adults with multiple chronic conditions. Peer-Reviewed Article September 2019
Home Alone Revisited: Family Caregivers Providing Complex Care Includes national survey data on family caregivers and their experiences in managing complex medical and nursing tasks for their family members at home, as well as recommendations to improve the supports for family caregivers. Brief/Report April 2019
Identifying and Designing the Right Care Management Program: Insights from ACOs Four care management models for ACOs. Implementation Tool April 2019
Health Care Transformation Task Force Value Partnership Evaluation Tool A tool for assessing readiness for value-based partnerships. Implementation Tool March 2019
High-Need, High-Cost Personas An in-depth overview of different personas. Implementation Tool February 2019
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 February 2019
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 May 2018
Systematic Review of High-Cost Patients’ Characteristics and Healthcare Utilisation An international analysis of high-cost patients. Peer-Reviewed Article July 2018
How ACOs Are Caring for People with Complex Needs An analysis of the National Survey of ACOs Brief/Report December 2018
Interventions for Frequently Hospitalized Patients and Their Effect on Outcomes: A Systematic Review Mixed evidence for efforts to reduce rehospitalizations. Peer-Reviewed Article December 2018
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 December 2018
Going Beyond Clinical Care to Reduce Health Care Spending A regional approach to health care transformation. Peer-Reviewed Article July 2018
A New Hospitalist Model for Managing High-Cost, High-Need Patients A hospitalist model for complex care. Case Example October 2018
Impact of Primary Care Intensive Management on High-Risk Veterans’ Costs and Utilization Supplementing primary care with team-based management. Peer-Reviewed Article June 2019
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