Leveraging the Social Determinants of Health: What Works?
This literature review assesses the impact of social service interventions.
Peer-Reviewed Article
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What Works in Integrated Care Programs for Older Adults with Complex Needs? A Realist Review
A literature review describes the most important success factors for integrated care programs.
Peer-Reviewed Article
The CHRONIC Care Act of 2018: Advancing Care for Adults with Complex Needs
A brief summarizes what you need to know about the new Chronic Care Act.
Brief/Report
Compendium of Five Case Studies: Lessons for Interprofessional Teamwork
The VA shares lessons on workforce learning and development.
Brief/Report
Restoring Dignity for Vulnerable Populations: Changing the System for Complex Patients
The benefits of holistic, team-based care go beyond medical needs.
Case Example
Designing a Health Care System for Patients with Complex Needs: Ten Recommendations for Policymakers
An international expert group offers ten policy recommendations and profiles of innovative care models.
Brief/Report
Accountable Care Atlas: A Development Guide for Competency Implementation
This resources describes the competencies organizations need to transition to value-based payment.
Implementation Tool
Competing Health Care Systems and Complex Patients: An Inter-Professional Collaboration
This paper describes competing health care systems can collaborate to improve care for overlapping patient populations.
Peer-Reviewed Article
Complex Care Models to Achieve Accountable Care Readiness: Lessons from Two Community Hospitals
Case studies of two community hospitals show how to advance accountable care.
Case Example
Interventions for Patients with Multimorbidity in Primary Care and Community Settings
A review of the evidence suggests it's difficult to improve outcomes for people with multimorbidity.
Peer-Reviewed Article
Nursing Student Coaches for Emergency Department Super Utilizers
Nursing students successfully coach patients with complex needs to avoid ED use.
Peer-Reviewed Article
Bending the Spending Curve: The Role of Care Management in a Pioneer ACO
ACOs have lowered costs for high-need patients through care management programs focused on modifiable spending.
Peer-Reviewed Article
Diffusion of Community Health Workers Within Medicaid Managed Care: A Strategy to Address Social Determinants of Health
New Mexico’s model to deploy community health workers is now replicated in 12 states.
Case Example
Multiple Chronic Conditions: A Framework for Education and Training
A framework describes how to train the health care workforce to care for people with multiple chronic conditions.
Implementation Tool
Evaluation of the Medicaid Health Home Option for Beneficiaries with Chronic Conditions: Annual Report - Year Three
This report presents the findings from the evaluation of Medicaid health homes, created as part of the Affordable Care Act.
Brief/Report
Complex Care Program Development: A New Framework for Design and Evaluation
A new framework outlines four steps to develop care management programs.
Brief/Report
State Strategies: Value-Based Payment for Medicaid Populations with Complex Care Needs
This brief describes Medicaid payment reform strategies for long-term services and support.
Brief/Report
Development of a Care Guidance Index Based on What Matters to Patients
The What Matters Index measures quality of life for people with chronic conditions.
Peer-Reviewed Article
Effective Care for High-Need Patients: Opportunities for Improving Value, Outcomes and Health
The National Academy of Medicine offers a synthesis of the evidence for improving care for high-needs patients.
Brief/Report
Improving Care for High-Need, High-Cost Medicare Patients
This Bipartisan Policy Center report makes policy recommendations to allow Medicare to pay for non-medical supports and services.
Brief/Report