Provides an overview of home-based medical care models, the patients that they serve, and their robust evidence base.

Describes factors that support health care organizations in transitioning from volume- to value-based payment.

Contains strategies, tips, and case studies to assist health care stakeholders in building meaningful, person-centered engagement in their organizations.

Describes the needs of distinct subpopulations within the dually eligible population with highly complex needs, along with opportunities for tailored interventions that may reduce health care spending.

Analysis of expanded supplemental benefit adoption for Medicare Advantage enrollees

Medicare patients with the top five percent in preventable utilization account for almost half of all avoidable Medicare costs.

Practical strategies for health plans and ACOs to improve care for patients with serious illness.

Demonstrating return-on-investment to advance effective business relationships between community-based organizations and health care partners.

How can a community-based organization demonstrate the two-way financial benefits of partnering with a health plan?

Effective complex care measures vary widely and need to be standardized to better align the field of complex care.

Among high-cost Medicare enrollees, those who are seriously ill, frail, and/or had a serious mental illness experience the most potentially preventable spending.

Providing virtual case mentoring to outpatient care teams may reduce unnecessary hospital and emergency department visits for high-need, high-cost patients.

Connecting complex care teams with specialists through videoconferencing can increase their effectiveness in caring for high-need high-cost patients.

Randomized controlled trial of a care management intervention offers important lessons for the field of complex care.

Recommendations for integrating social and health care to improve the nation’s health.

Impact of social needs navigation program on future utilization of patients with prior high utilization.

A standardized tool to assess where along a continuum a program lies with regard to components of integration.

How ACOs are addressing serious illness.

This toolkit details the benefits of home-based primary care to help providers demonstrate the need for these programs.

Includes case studies, clinical assessment tools, and other resources for identifying and assessing the needs of patients with serious illness.