Impact of Primary Care Intensive Management on High-Risk Veterans’ Costs and Utilization Supplementing primary care with team-based management. Peer-Reviewed Article June 2019
Aging Gracefully: The PACE Approach to Caring for Frail Elders in the Community Reviews lessons from the Program of All-Inclusive Care for the Elderly on serving high-need populations in community settings. Case Example August 2016
Academic Medical Centers and High-Need, High-Cost Patients: A Call to Action This resource describes how academic medical centers can reshape the health system for patients with complex needs. Peer-Reviewed Article November 2018
Active Redesign of a Medicaid Care Management Strategy for Greater Return on Investment: Predicting Impactability This resource describes one tool to identify patients most likely to benefit from care management. Peer-Reviewed Article April 2018
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 June 2017
Community Health Worker Support for Disadvantaged Patients with Multiple Chronic Diseases: A Randomized Clinical Trial This resource describes the benefits of community health workers for people with multiple chronic conditions. Peer-Reviewed Article October 2017
What Works in Integrated Care Programs for Older Adults with Complex Needs? A Realist Review A literature review describes the most important success factors for integrated care programs. Peer-Reviewed Article October 2017
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 March 2018
Complex Care Program Development: A New Framework for Design and Evaluation A new framework outlines four steps to develop care management programs. Brief/Report March 2017
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 June 2017
House Calls: California Program For Homebound Patients Reduces Monthly Spending, Delivers Meaningful Care A novel approach to home visiting delivers cost reduction and better care Peer-Reviewed Article January 2016
So Many Options, Where Do We Start? An Overview of the Care Transitions Literature A systemic review of transitional care interventions reporting hospital readmission Peer-Reviewed Article March 2016
CareMore: Improving Outcomes and Controlling Health Care Spending for High-Needs Patients CareMore’s business model identifies high-risk patients and surrounds them with coordinated services Case Example March 2017
Innovative Home Visit Models Associated with Reductions in Costs, Hospitalizations, and Emergency Department Use Home visits can reach patients with complex needs before a higher level of care is needed Peer-Reviewed Article March 2017
The Health Resilience Program: A Program Assessment Health Resilience Specialists work with the patients to meet their personal health needs Case Example January 2016
High-Intensity Telemedicine Decreases Emergency Department Use for Ambulatory Care Sensitive Conditions by Older Adult Senior Living Community Residents Telemedicine may expand access to acute illness care and reduce emergency department visits for older adults. Peer-Reviewed Article December 2015
New Models of Primary Care Workforce and Financing: Case Example #1: Stanford Coordinated Care Stanford Coordinated Care provides university employees with complex health needs better care at a lower cost Case Example October 2016
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 September 2016
The Business Case for Community Paramedicine: Lessons from Commonwealth Care Alliance’s Pilot Program Cost considerations for the expansion of mobile integrated health care and community paramedicine programs. Case Example December 2016
Intensive Outpatient Care Program Toolkit The staff position of care coordinator is crucial to success. Implementation Tool December 2016