Displaying 421 - 437 of 437

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

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

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

May 2016

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

September 2016

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

August 2016

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

January 2016

Generating Hypotheses about Care Needs of High Utilizers: Lessons from Patient Interviews

This resource presents promising ideas for more effective modes of care for persons with complex needs.

Peer-Reviewed Article

September 2013

Hennepin Health: A Care Delivery Paradigm for New Medicaid Beneficiaries

By closing gaps in care, a safety-net ACO has reduced medical costs for Medicaid patients with complex needs.

Case Example

October 2016

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

March 2016

Using Data to Better Serve the Most Complex Patients: Highlights from NGA’s Intensive Work with Seven States

The National Governors Association worked for two years to improve care and lower costs for Medicaid “super-utilizers.”

Brief/Report

August 2019

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

April 2016

Emergency Department Super-Utilizer Programs: Rural Health Systems Analysis and Technical Assistance Project

This guide describes how to design, implement, and assess a program to reduce preventable ED use.

Implementation Tool

October 2013

The Core of Care Management: The Role of Authentic Relationships in Caring for Patients with Frequent Hospitalizations

This study links “authentic healing relationships” with patient motivation and active health management.

Peer-Reviewed Article

August 2016

Project ECHO’s Complex Care Initiative: Building Capacity to Help “Superutilizers”

Interdisciplinary teams provide support for Medicaid beneficiaries with mental illnesses, addictions, and other needs.

Case Example

August 2016

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

October 2015

The Return on Investment (ROI) Calculator: The Business Case and Person-Centered Care

A calculator that can help build and present business case for serving adults with complex needs.

Implementation Tool

November 2016

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

September 2015

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

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

Payment to Promote Sustainability of Care Management Models for High-Need, High-Cost Patients

What Matters Most: Essential Attributes of a High-Quality System of Care for Adults with Complex Care Needs

High-Need, High-Cost Patients: Who Are They and How Do They Use Health Care?

How High-Need Patients Experience the Health Care System in Nine Countries

Generating Hypotheses about Care Needs of High Utilizers: Lessons from Patient Interviews

Hennepin Health: A Care Delivery Paradigm for New Medicaid Beneficiaries

Adding a Measure of Self-Management Capability to Risk Assessment Can Improve Prediction of High Costs

Using Data to Better Serve the Most Complex Patients: Highlights from NGA’s Intensive Work with Seven States

Key Components for Successful LTSS Integration: Lessons from Five Exemplar Plans

Emergency Department Super-Utilizer Programs: Rural Health Systems Analysis and Technical Assistance Project

The Core of Care Management: The Role of Authentic Relationships in Caring for Patients with Frequent Hospitalizations

Project ECHO’s Complex Care Initiative: Building Capacity to Help “Superutilizers”

Models of Care for High-Need, High-Cost Patients: An Evidence Synthesis

The Return on Investment (ROI) Calculator: The Business Case and Person-Centered Care

Supporting a Culture of Health: Opportunities to Improve Models of Care for People with Complex Needs