Interventions for Frequently Hospitalized Patients and Their Effect on Outcomes: A Systematic Review
Mixed evidence for efforts to reduce rehospitalizations.
Peer-Reviewed Article
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Blueprint for Complex Care: Advancing the Field of Care for Individuals with Complex Health and Social Needs
This resource outlines the current state of complex care and recommendations for the future.
Implementation Tool
Patient Engagement in ACO Practices and Patient-Reported Outcomes Among Adults with Co-Occurring Chronic Disease and Mental Health Conditions
Patient engagement improves patient-reported outcomes.
Peer-Reviewed Article
Patterns of Collaboration among Health Care and Social Services Providers in Communities with Lower Health Care Utilization and Costs
Community approaches to reducing care utilization and costs.
Peer-Reviewed Article
Going Beyond Clinical Care to Reduce Health Care Spending
A regional approach to health care transformation.
Peer-Reviewed Article
A New Hospitalist Model for Managing High-Cost, High-Need Patients
A hospitalist model for complex care.
Case Example
Impact of Primary Care Intensive Management on High-Risk Veterans’ Costs and Utilization
Supplementing primary care with team-based management.
Peer-Reviewed Article
Case Managers for High-Risk, High-Cost Patients as Agents and Street-Level Bureaucrats
How to improve the cost benefits of case management.
Peer-Reviewed Article
Persistence and Drivers of High-Cost Status Among Dual-Eligible Medicare and Medicaid Beneficiaries
Analyzes the largest drivers of high costs among persistently high-cost Medicare-Medicaid beneficiaries, and finds most spending related to long-term care.
Peer-Reviewed Article
Academic Medical Centers and High-Need, High-Cost Patients: A Call to Action
This resource describes how academic medical centers can reshape the health system for patients with complex needs.
Peer-Reviewed Article
Active Redesign of a Medicaid Care Management Strategy for Greater Return on Investment: Predicting Impactability
This resource describes one tool to identify patients most likely to benefit from care management.
Peer-Reviewed Article
Integrating Health Care for High-Need Medicaid Beneficiaries With Serious Mental Illness and Chronic Physical Health Conditions at Managed Care, Provider, and Consumer Levels
This resource describes the value of navigators for Medicaid beneficiaries with mental illness.
Peer-Reviewed Article
The ROI Calculator for Partnerships to Address the Social Determinants of Health
A web-based financial tool that helps navigate partnerships between health care organizations and social service organizations.
Implementation Tool
Building Complex Care Programs: A Road Map for States
This guide for state leaders offers lessons about state-level approaches to complex care.
Implementation Tool
Care Management Contracting for Complex Populations: Best Practices and Tools
This resource offers guidance on contracting for populations with complex needs.
Implementation Tool
Community Health Worker Support for Disadvantaged Patients with Multiple Chronic Diseases: A Randomized Clinical Trial
This resource describes the benefits of community health workers for people with multiple chronic conditions.
Peer-Reviewed Article
Managing Effectively in Complex Chronic Care Markets
This resource provides a road map for health plans to improve Medical Loss Ratio.
Peer-Reviewed Article
Medicaid Managed Care Best Practices Compendium
This resource collects the most innovative initiatives in Medicaid managed care that emerge each year.
Brief/Report
Investing in Social Services as a Core Strategy for Healthcare Organizations: Developing the Business Case
This resource explains how to invest in social services as a business strategy.
Implementation Tool
Using Community Partnerships to Integrate Health and Social Services for High-Need, High-Cost Patients
This brief describes new ways for health care to address social determinants of health.
Brief/Report