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

CAPABLE, a home-based care program that provides interdisciplinary services for older adults, leads to reductions in disability as well as cost savings.

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.

Primary care and alternative payment models that reduce emergency department use and increase access to care for high-need populations share core components for success.

An affordable housing program in Baltimore generates between $1.30-$1.92 of “social return” in the community for every dollar invested annually.

Provides practical steps for current or potential future Medicare accountable care organizations to transform the delivery of care, including through telehealth, home visits, and skilled nursing care.

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.

Examines promising strategies to meet the needs of dually eligible individuals with serious mental illness, with an emphasis on opportunities to innovate with flexible spending within a capitated payment model.

Complex care management program within Next Generation Accountable Care Organizations reduced cost and utilization for high-risk Medicare beneficiaries.

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

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

Accountable care organizations must address key funding, community partnership, and data sharing requirements to successfully integrate social services into medical care.

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

Accountable Care Organization leaders explore approaches to segmenting high-need, high-cost populations.

How home visits are used by ACOs to improve care, lower costs.

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

How ACOs can improve care coordination.

Four care management models for ACOs.

This resource is an updated quick reference guide to promising models for people with complex needs.