Case Management in Primary Care for Frequent Users of Health Care Services: A Mixed Methods Study
The psychological benefits of case management.
Peer-Reviewed Article
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Re-envisioning Care for People with Involved Disabilities
Video series details how health systems can redesign primary care, including through home-based primary care programs, to better meet the needs of people with disabilities.
Implementation Tool
Outcomes of a Citywide Campaign to Reduce Medicaid Hospital Readmissions with Connection to Primary Care Within 7 Days of Hospital Discharge
The importance of timely primary care follow-up.
Peer-Reviewed Article
Impact of a Complex Chronic Care Patient Case Conference on Quality and Utilization
The case conference approach to caring for complex patients.
Peer-Reviewed Article
Impact of Primary Care Intensive Management on High-Risk Veterans’ Costs and Utilization
Supplementing primary care with team-based management.
Peer-Reviewed Article
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
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
The Health Resilience Program: A Program Assessment
Health Resilience Specialists work with the patients to meet their personal health needs
Case Example
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
Care Management Plus: Strengthening Primary Care for Patients with Multiple Chronic Conditions
A program to help clinics deliver comprehensive care may decrease mortality and hospitalization rates.
Case Example
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
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