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
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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
Caring for High-Need, High-Cost Patients: What Makes for a Successful Care Management Program?
A comparison of 18 complex care management programs reveals best practices.
Brief/Report
Effective Management of High-Risk Medicare Populations
A three-pronged strategy can help manage care for Medicare beneficiaries.
Brief/Report
Six Features of Medicare Coordinated Care Demonstration Programs that Cut Hospital Admissions
A study showed that some programs reduced hospitalizations by 8 to 33 percent.
Peer-Reviewed Article
Persistent High Utilization in a Privately Insured Population
This resource takes a close look at individuals with complex needs who are privately insured.
Peer-Reviewed Article
Improving Care for People with Serious Illness Through Innovative Payer-Provider Partnerships
The benefits of, incentives for, and various models to deliver palliative care are described.
Implementation Tool
Person-Centered Care: The Business Case
Federal policy changes have made PCC models of care more financially viable.
Brief/Report
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
Guided Care: A Structured Approach to Providing Comprehensive Primary Care for Complex Patients
Guided Care is designed to strike a balance between telephone-based and interdisciplinary team-based care management programs.
Case Example
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
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
Person-Centered Care: A Definition and Essential Elements
This resource provides a definition and essential elements of person-centered care.
Peer-Reviewed Article
Pursuing Financial Sustainability of Person-Centered Care Models
Setting up data collection systems is important to showing value.
Implementation Tool
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