The staff position of care coordinator is crucial to success.

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.

Segmenting the high-cost population is the first step in matching appropriate care management strategies.

Care management programs should include processes for evaluating patient-reported outcomes.

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.

The approach identifies patients through chart review and data analytics coupled with the intelligence of community health workers.

Assessing patients’ activation levels can help identify those at risk for poor health outcomes and utilization of avoidable, costly care.

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.

A program to help clinics deliver comprehensive care may decrease mortality and hospitalization rates.

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

There is considerable variation in use and spending among high-need adults, suggesting this population should be segmented into subgroups.

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

Targeting is important, even within the high-need patients enrolled in the program.

This resource presents promising ideas for more effective modes of care for persons with complex needs.

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

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

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

Less “activated” patients are more likely to benefit from care coordination.