A set of resources and strategies to help health care stakeholders foster authentic, effective community engagement that drives local policy and program change.

Website offers a qualitative database of personal narratives to support providers and policymakers in designing policies that better reflect the lived experience, needs, and priorities of older adults.

Using “equity weighting” may improve quality measurement efforts intending to advance health equity for underserved groups.

A home-based palliative care program leads to reductions in hospitalizations and total cost of care, along with an increase in the use of hospice care.

An interdisciplinary home-based primary care program for older adults with limited mobility leads to reductions in health care utilization and costs.

Including spiritual care within care management programs in outpatient, managed care, and population health settings can enhance patient care and support the effectiveness of the interdisciplinary care team.

Describes the core elements and evidence base behind a home- and community-based palliative care model that was designed by stakeholders to support the health needs of people with serious illness.

This guide describes key strategies for health plans, accountable care organizations, and health systems to improve care for people with serious illness.

Home-based palliative care providers explore key facilitators and barriers to effectively delivering care within a value-based payment environment.

Explored how complex care stakeholders can incorporate a multi-factor approach to measure and demonstrate the value of complex care programs for diverse stakeholders.

Segmentation framework with publicly available code files identifies specific and actionable patient cohorts with complex needs.

This toolkit shares business strategies, sample protocols, and best practice clinical tools for health care providers interested in developing a home-based palliative care program.

Home-based palliative care program implemented within an accountable care organization created cost savings through reduced hospital admissions and increased hospice length of stay.

This case study analyzes a successful example of a medical group partnering with a home health agency to provide community-based palliative care for high-risk members of their accountable care organization.

This case study highlights an accountable care organization’s home-based primary care program for homebound older adults, with early analysis of outcomes showing reduced acute care utilization.

Clinical tools, training resources, and case studies of evidence-based care models that support people living with dementia and their caregivers.

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.

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.