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
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CareMore: Improving Outcomes and Controlling Health Care Spending for High-Needs Patients
CareMore’s business model identifies high-risk patients and surrounds them with coordinated services
Case Example
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
The Health Resilience Program: A Program Assessment
Health Resilience Specialists work with the patients to meet their personal health needs
Case Example
The Business Case for Community Paramedicine: Lessons from Commonwealth Care Alliance’s Pilot Program
Cost considerations for the expansion of mobile integrated health care and community paramedicine programs.
Case Example
Intensive Outpatient Care Program Toolkit
The staff position of care coordinator is crucial to success.
Implementation Tool
Tailoring Complex Care Management, Coordination, and Integration for High-Need, High-Cost Patients
Improving care for high-need, high-cost patients is a key lever to decrease national health spending.
Brief/Report
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
Proactively Identifying the High-Cost Population
Segmenting the high-cost population is the first step in matching appropriate care management strategies.
Brief/Report
Developing Care Management Programs to Serve High-Need, High-Cost Populations
Care management programs should include processes for evaluating patient-reported outcomes.
Brief/Report
Utilization of Hot Spotting to Identify Community Needs and Coordinate Care for Patients in Memphis, TN
The approach identifies patients through chart review and data analytics coupled with the intelligence of community health workers.
Peer-Reviewed Article
Delivery System Reform: Improving Care for Individuals Dually Eligible for Medicare and Medicaid
Dual-eligible beneficiaries are often more sick, have greater functional and cognitive impairments, and require more care coordination.
Brief/Report
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
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
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
Adding a Measure of Self-Management Capability to Risk Assessment Can Improve Prediction of High Costs
Less “activated” patients are more likely to benefit from care coordination.
Peer-Reviewed Article
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