Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation’s Health
Recommendations for integrating social and health care to improve the nation’s health.
Brief/Report
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Displaying 161 - 178 of 178
Impact of Supportive Housing on Substance Use-Related Health Care Utilization Among Homeless Persons who are Active Substance Users
Supportive housing placement for people with substance use disorder (SUD) who are homeless reduces SUD-related health care utilization.
Peer-Reviewed Article
Are Medicare Advantage Plans Using New Supplemental Benefit Flexibility to Address Enrollees’ Health-Related Social Needs?
Multiple factors, including geographic variation in available resources, may limit take-up among MA plans of new benefit flexibilities.
Brief/Report
A Turning Point in Medicare Policy: Guiding Principles for New Flexibility Under Special Supplemental Benefits for the Chronically Ill
How to implement the new Medicare benefits.
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
Engaging High-Need Patients in Intensive Outpatient Programs: A Qualitative Synthesis of Engagement Strategies
Overcoming barriers to patient engagement.
Peer-Reviewed Article
Patterns of Collaboration among Health Care and Social Services Providers in Communities with Lower Health Care Utilization and Costs
Community approaches to reducing care utilization and costs.
Peer-Reviewed Article
Going Beyond Clinical Care to Reduce Health Care Spending
A regional approach to health care transformation.
Peer-Reviewed Article
The ROI Calculator for Partnerships to Address the Social Determinants of Health
A web-based financial tool that helps navigate partnerships between health care organizations and social service organizations.
Implementation Tool
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
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
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
Developing Care Management Programs to Serve High-Need, High-Cost Populations
Care management programs should include processes for evaluating patient-reported outcomes.
Brief/Report
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
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
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
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