Displaying 161 - 175 of 175

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

March 2016

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

March 2016

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

March 2017

The Health Resilience Program: A Program Assessment

Health Resilience Specialists work with the patients to meet their personal health needs

Case Example

January 2016

Strategies for Change—A Collaborative Journey to Transform Advanced Illness Care

Person-centered preferences can inform approaches to advanced illness care

Brief/Report

November 2016

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

December 2016

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

January 2016

Proactively Identifying the High-Cost Population

Segmenting the high-cost population is the first step in matching appropriate care management strategies.

Brief/Report

July 2015

Developing Care Management Programs to Serve High-Need, High-Cost Populations

Care management programs should include processes for evaluating patient-reported outcomes.

Brief/Report

February 2016

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

May 2016

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

September 2016

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

August 2016

Improving Care for People with Serious Illness Through Innovative Payer-Provider Partnerships

The benefits of, incentives for, and various models to deliver palliative care are described.

Implementation Tool

January 2014

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

November 2016

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

September 2015

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Bridging the Silos of Service Delivery for High-Need, High-Cost Individuals

So Many Options, Where Do We Start? An Overview of the Care Transitions Literature

Innovative Home Visit Models Associated with Reductions in Costs, Hospitalizations, and Emergency Department Use

The Health Resilience Program: A Program Assessment

Strategies for Change—A Collaborative Journey to Transform Advanced Illness Care

How High-Need Patients Experience Health Care in the United States

Overview of Segmentation of High-Need, High-Cost Patient Population

Proactively Identifying the High-Cost Population

Developing Care Management Programs to Serve High-Need, High-Cost Populations

Payment to Promote Sustainability of Care Management Models for High-Need, High-Cost Patients

What Matters Most: Essential Attributes of a High-Quality System of Care for Adults with Complex Care Needs

The Hospital at Home Model: Bringing Hospital-Level Care to the Patient

Improving Care for People with Serious Illness Through Innovative Payer-Provider Partnerships

The Return on Investment (ROI) Calculator: The Business Case and Person-Centered Care

Supporting a Culture of Health: Opportunities to Improve Models of Care for People with Complex Needs