Multiple Chronic Conditions: A Framework for Education and Training
A framework describes how to train the health care workforce to care for people with multiple chronic conditions.
Implementation Tool
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Displaying 561 - 580 of 615
Evaluation of the Medicaid Health Home Option for Beneficiaries with Chronic Conditions: Annual Report - Year Three
This report presents the findings from the evaluation of Medicaid health homes, created as part of the Affordable Care Act.
Brief/Report
Complex Care Program Development: A New Framework for Design and Evaluation
A new framework outlines four steps to develop care management programs.
Brief/Report
Development of a Care Guidance Index Based on What Matters to Patients
The What Matters Index measures quality of life for people with chronic conditions.
Peer-Reviewed Article
Serious Illness Conversation Guide
This conversation guide includes specific steps and language for talking about serious illness.
Implementation Tool
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
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
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
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
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
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
The Health Resilience Program: A Program Assessment
Health Resilience Specialists work with the patients to meet their personal health needs
Case Example
Strategies for Change—A Collaborative Journey to Transform Advanced Illness Care
Person-centered preferences can inform approaches to advanced illness care
Brief/Report
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
Characteristics of Hospital and Emergency Care Super-Utilizers with Multiple Chronic Conditions
Patients with a history of high health care utilization may be a good target for a care transition intervention
Peer-Reviewed Article
How High-Need Patients Experience Health Care in the United States
This 2016 survey reveals that the health care system is failing people with complex needs
Brief/Report
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
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
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
Key Ingredients for Successful Trauma-Informed Care Implementation
Trauma-informed care can improve patient engagement and treatment adherence while reducing costs.
Brief/Report