ACO Serious Illness Care: Survey and Case Studies Depict Current Challenges and Future Opportunities
How ACOs are addressing serious illness.
Peer-Reviewed Article
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The Opioid Use Disorder Prevention Playbook
Strategies for preventing opioid use disorder.
Implementation Tool
Quick Reference Guide to Promising Care Models
This resource is an updated quick reference guide to promising models for people with complex needs.
Brief/Report
Outpatient Complex Case Management: Health System-Tailored Risk Stratification Taxonomy to Identify High-Cost, High-Need Patients
Maximizing the impact of outpatient complex 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
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
Innovations in Medicare Advantage to Improve Care for Seriously Ill Patients
This resource describes how MA could lead the way in diffusing new care and payment models.
Brief/Report
Medicaid Managed Care Best Practices Compendium
This resource collects the most innovative initiatives in Medicaid managed care that emerge each year.
Brief/Report
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
Leveraging the Social Determinants of Health: What Works?
This literature review assesses the impact of social service interventions.
Peer-Reviewed Article
Ten Questions to Better Understand and Serve Your Complex Care Population
California is asking Medicaid patients these ten questions about social and functional needs.
Brief/Report
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
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
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
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
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
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
Home-Based Care Program Reduces Disability and Promotes Aging in Place
Difficulty with activities of daily living is a major cost driver in health care that is typically overlooked.
Peer-Reviewed Article
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