A brief summarizes what you need to know about the new Chronic Care Act.

This framework can help you design programs for patients with serious illnesses.

The National Academy of Medicine offers a synthesis of the evidence for improving care for high-needs patients.

A study of five programs identified key factors that support collaboration among community-based health and social services.

A novel approach to home visiting delivers cost reduction and better care

CareMore’s business model identifies high-risk patients and surrounds them with coordinated services

Difficulty with activities of daily living is a major cost driver in health care that is typically overlooked.

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.

The program offers a lower-cost alternative to the hospital for patients who can be safely treated at home.

The Care Transitions Intervention was co-designed with patients and evaluated using randomized trials.

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

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

The benefits of, incentives for, and various models to deliver palliative care are described.