Payment to Promote Sustainability of Care Management Models for High-Need, High-Cost Patients
Provider incentives must be based on Triple Aim outcomes.
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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
High-Need, High-Cost Patients: Who Are They and How Do They Use Health Care?
There is considerable variation in use and spending among high-need adults, suggesting this population should be segmented into subgroups.
Brief/Report
How High-Need Patients Experience the Health Care System in Nine Countries
The U.S. had the highest rate of cost-related access problems.
Brief/Report
Attributes Common to Programs That Successfully Treat High-Need, High-Cost Individuals
Targeting is important, even within the high-need patients enrolled in the program.
Peer-Reviewed Article
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
The Care Transitions Intervention
The Care Transitions Intervention was co-designed with patients and evaluated using randomized trials.
Implementation Tool
Key Components for Successful LTSS Integration: Lessons from Five Exemplar Plans
Successful long-term services and supports programs have a single point of accountability, such as a care manager.
Brief/Report
Person-Centered Care: The Business Case
Federal policy changes have made PCC models of care more financially viable.
Brief/Report
Guided Care: A Structured Approach to Providing Comprehensive Primary Care for Complex Patients
Guided Care is designed to strike a balance between telephone-based and interdisciplinary team-based care management programs.
Case Example
Models of Care for High-Need, High-Cost Patients: An Evidence Synthesis
Much of the evidence comes from small studies, so further testing is needed.
Brief/Report
Person-Centered Care: A Definition and Essential Elements
This resource provides a definition and essential elements of person-centered care.
Peer-Reviewed Article
Pursuing Financial Sustainability of Person-Centered Care Models
Setting up data collection systems is important to showing value.
Implementation Tool
Complex Care Management Toolkit
Lessons learned from eight health care organizations can help you design a successful program.
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