Displaying 361 - 380 of 407

Bridging the Silos of Service Delivery for High-Need, High-Cost Individuals

A study of five programs identified key factors that support collaboration among community-based health and social services.

Peer-Reviewed Article

March 2016

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

March 2016

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

March 2017

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

March 2017

The Health Resilience Program: A Program Assessment

Health Resilience Specialists work with the patients to meet their personal health needs

Case Example

January 2016

Characteristics of Hospital and Emergency Care Super-Utilizers with Multiple Chronic Conditions

Patients with a history of high health care utilization may be a good target for a care transition intervention

Peer-Reviewed Article

April 2016

How High-Need Patients Experience Health Care in the United States

This 2016 survey reveals that the health care system is failing people with complex needs

Brief/Report

December 2016

New Models of Primary Care Workforce and Financing: Case Example #1: Stanford Coordinated Care

Stanford Coordinated Care provides university employees with complex health needs better care at a lower cost

Case Example

October 2016

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

December 2016

Challenges and Opportunities in Caring for High-Need, High-Cost Medicare Patients

Analysis of care models that serve Medicare-only individuals detailing policy barriers to providing uncovered services and supports and proposed strategies to address them.

Brief/Report

February 2017

Community Care Teams: An Overview of State Approaches

The composition of teams varies depending on state staffing requirements and community resources.

Brief/Report

March 2016

Key Ingredients for Successful Trauma-Informed Care Implementation

Trauma-informed care can improve patient engagement and treatment adherence while reducing costs.

Brief/Report

April 2016

Intensive Outpatient Care Program Toolkit

The staff position of care coordinator is crucial to success.

Implementation Tool

December 2016

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

September 2016

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

January 2016

Proactively Identifying the High-Cost Population

Segmenting the high-cost population is the first step in matching appropriate care management strategies.

Brief/Report

July 2015

Developing Care Management Programs to Serve High-Need, High-Cost Populations

Care management programs should include processes for evaluating patient-reported outcomes.

Brief/Report

February 2016

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

February 2014

Improving Population Health Management Strategies: Identifying Likely Users of Avoidable Costly Care

Assessing patients’ activation levels can help identify those at risk for poor health outcomes and utilization of avoidable, costly care.

Peer-Reviewed Article

August 2016

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

September 2016

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Bridging the Silos of Service Delivery for High-Need, High-Cost Individuals

So Many Options, Where Do We Start? An Overview of the Care Transitions Literature

CareMore: Improving Outcomes and Controlling Health Care Spending for High-Needs Patients

Innovative Home Visit Models Associated with Reductions in Costs, Hospitalizations, and Emergency Department Use

The Health Resilience Program: A Program Assessment

Characteristics of Hospital and Emergency Care Super-Utilizers with Multiple Chronic Conditions

How High-Need Patients Experience Health Care in the United States

New Models of Primary Care Workforce and Financing: Case Example #1: Stanford Coordinated Care

The Business Case for Community Paramedicine: Lessons from Commonwealth Care Alliance’s Pilot Program

Challenges and Opportunities in Caring for High-Need, High-Cost Medicare Patients

Community Care Teams: An Overview of State Approaches

Key Ingredients for Successful Trauma-Informed Care Implementation

Intensive Outpatient Care Program Toolkit

Tailoring Complex Care Management, Coordination, and Integration for High-Need, High-Cost Patients

Overview of Segmentation of High-Need, High-Cost Patient Population

Proactively Identifying the High-Cost Population

Developing Care Management Programs to Serve High-Need, High-Cost Populations

Utilization of Hot Spotting to Identify Community Needs and Coordinate Care for Patients in Memphis, TN

Improving Population Health Management Strategies: Identifying Likely Users of Avoidable Costly Care

Delivery System Reform: Improving Care for Individuals Dually Eligible for Medicare and Medicaid