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.
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Displaying 101 - 119 of 119
Nursing Student Coaches for Emergency Department Super Utilizers
Nursing students successfully coach patients with complex needs to avoid ED use.
Peer-Reviewed Article
Bending the Spending Curve: The Role of Care Management in a Pioneer ACO
ACOs have lowered costs for high-need patients through care management programs focused on modifiable spending.
Peer-Reviewed Article
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
Complex Care Program Development: A New Framework for Design and Evaluation
A new framework outlines four steps to develop care management programs.
Brief/Report
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
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
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
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
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 Return on Investment (ROI) Calculator: The Business Case and Person-Centered Care
A calculator that can help build and present business case for serving adults with complex needs.
Implementation Tool
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