So Many Options, Where Do We Start? An Overview of the Care Transitions Literature
A systemic review of transitional care interventions reporting hospital readmission
Peer-Reviewed Article
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Displaying 121 - 133 of 133
Innovative Home Visit Models Associated with Reductions in Costs, Hospitalizations, and Emergency Department Use
Home visits can reach patients with complex needs before a higher level of care is needed
Peer-Reviewed Article
The Health Resilience Program: A Program Assessment
Health Resilience Specialists work with the patients to meet their personal health needs
Case Example
How High-Need Patients Experience Health Care in the United States
This 2016 survey reveals that the health care system is failing people with complex needs
Brief/Report
Challenges and Opportunities in Caring for High-Need, High-Cost Medicare Patients
Analysis of care models that serve Medicare-only individuals detailing policy barriers to providing uncovered services and supports and proposed strategies to address them.
Brief/Report
Overview of Segmentation of High-Need, High-Cost Patient Population
There are many promising strategies to segment individuals with complex needs. Here is one conceptual framework.
Implementation Tool
Proactively Identifying the High-Cost Population
Segmenting the high-cost population is the first step in matching appropriate care management strategies.
Brief/Report
Developing Care Management Programs to Serve High-Need, High-Cost Populations
Care management programs should include processes for evaluating patient-reported outcomes.
Brief/Report
Payment to Promote Sustainability of Care Management Models for High-Need, High-Cost Patients
Provider incentives must be based on Triple Aim outcomes.
Brief/Report
What Matters Most: Essential Attributes of a High-Quality System of Care for Adults with Complex Care Needs
Experts describe how delivery systems can effectively serve adults with complex needs.
Brief/Report
The Hospital at Home Model: Bringing Hospital-Level Care to the Patient
The program offers a lower-cost alternative to the hospital for patients who can be safely treated at home.
Case Example
Effective Management of High-Risk Medicare Populations
A three-pronged strategy can help manage care for Medicare beneficiaries.
Brief/Report
Supporting a Culture of Health: Opportunities to Improve Models of Care for People with Complex Needs
Key opportunities include strengthening information technology connections across service providers.
Brief/Report