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

Improving care for high-need, high-cost patients is a key lever to decrease national health spending.

There are many promising strategies to segment individuals with complex needs. Here is one conceptual framework.

Examines a unique program that seeks to integrate medical, behavioral health, and social services for dual eligible individuals with serious mental illnesses, substance abuse problems, or disabilities.

Dual-eligible beneficiaries are often more sick, have greater functional and cognitive impairments, and require more care coordination.

Provider incentives must be based on Triple Aim outcomes.

Well-designed federal policies can help meet the rising need.

Experts describe how delivery systems can effectively serve adults with complex needs.

The U.S. had the highest rate of cost-related access problems.

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

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

Successful long-term services and supports programs have a single point of accountability, such as a care manager.

A three-pronged strategy can help manage care for Medicare beneficiaries.

A study showed that some programs reduced hospitalizations by 8 to 33 percent.

One in five high-need adults reported having an unmet medical need.

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

Key opportunities include strengthening information technology connections across service providers.