Displaying 1 - 19 of 19

The People Say

Website offers a qualitative database of personal narratives to support providers and policymakers in designing policies that better reflect the lived experience, needs, and priorities of older adults.

Implementation Tool

August 2025

Association of a Medicare Advantage Posthospitalization Home Meal Delivery Benefit With Rehospitalization and Death

Home-delivered meals reduced rates of 30-day rehospitalization and death for Medicare Advantage members post hospitalization.

Peer-Reviewed Article

June 2023

Bridging the Home-Based Primary Care Gap in Rural Areas

Interdisciplinary care teams, telehealth, and flexible payment models are included as key recommendations to increase access to home-based primary care in rural communities.

Brief/Report

February 2024

Does Interdisciplinary Care Team Care Management Improve Health Quality and Demonstrate Cost-Effectiveness?

An interdisciplinary care management program for Medicare patients at increased risk of hospitalization demonstrates a positive return on investment.

Peer-Reviewed Article

September 2023

A Clinical Pathway to Well-Being: Putting Patient Priorities at the Center of Care

A care management model designed to center patients’ health priorities shows promising results.

Peer-Reviewed Article

October 2023

Addressing Healthcare Utilization and Costs for Older Adults with Limited Mobility Through a Multidisciplinary Home-Based Primary Care Program

An interdisciplinary home-based primary care program for older adults with limited mobility leads to reductions in health care utilization and costs.

Peer-Reviewed Article

August 2023

Redesign of a Primary Care-Based Housing Intervention to Address Upstream Housing Needs

A primary care practice redesigned its social needs screening and patient triage process to allow specialized staff to spend more time supporting patients with more intensive housing needs.

Case Example

July 2023

Trade-Offs in Locational Choices for Care Coordination Resources in Accountable Care Organizations

Having onsite care coordinators may significantly improve the quality of patient care, while centralized coordination is associated with increased information sharing.

Peer-Reviewed Article

July 2023

Community Health Worker Integration with and Effectiveness in Health Care and Public Health in the United States

Community health worker interventions are effective for improving health behaviors and outcomes and reducing health care costs for people with chronic disease.

Peer-Reviewed Article

April 2023

Observational Analysis of a Generalized, Health Plan-led Community Health Worker Intervention in Medicaid

Medicaid health plan-led community health worker program showed moderate evidence for increased outpatient care and primary care use.

Peer-Reviewed Article

January 2023

Promoting High-Value Care through Telehealth

Features a conversation with Ateev Mehrotra, MD, MPH, professor of health care policy at Harvard Medical School, that explores opportunities to use value-based payment strategies to support telehealth for people with complex needs.

Blog

February 2022

Home-Based Primary Care Interventions

Systematic review demonstrates the potential of home-based primary care interventions for improving heath, cost, and patient experience outcomes for adults with multiple chronic conditions and serious disabilities.

Peer-Reviewed Article

February 2016

Providing Primary Care to Homebound Patients: UCSF Health's Care at Home Program

This case study highlights an accountable care organization’s home-based primary care program for homebound older adults, with early analysis of outcomes showing reduced acute care utilization.

Case Example

August 2020

A Systematic Review of Primary Care and Payment Models on Emergency Department Use in Patients Classified as High Need, High Cost

Primary care and alternative payment models that reduce emergency department use and increase access to care for high-need populations share core components for success.

Peer-Reviewed Article

March 2021

‘Eyes in The Home’: ACOs Use Home Visits to Improve Care Management, Identify Needs, And Reduce Hospital Use

How home visits are used by ACOs to improve care, lower costs.

Peer-Reviewed Article

June 2019

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

Bending the Spending Curve: The Role of Care Management in a Pioneer ACO

ACOs have lowered costs for high-need patients through care management programs focused on modifiable spending.

Peer-Reviewed Article

May 2017

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

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

October 2016

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The People Say

Association of a Medicare Advantage Posthospitalization Home Meal Delivery Benefit With Rehospitalization and Death

Bridging the Home-Based Primary Care Gap in Rural Areas

Does Interdisciplinary Care Team Care Management Improve Health Quality and Demonstrate Cost-Effectiveness?

A Clinical Pathway to Well-Being: Putting Patient Priorities at the Center of Care

Addressing Healthcare Utilization and Costs for Older Adults with Limited Mobility Through a Multidisciplinary Home-Based Primary Care Program

Redesign of a Primary Care-Based Housing Intervention to Address Upstream Housing Needs

Trade-Offs in Locational Choices for Care Coordination Resources in Accountable Care Organizations

Community Health Worker Integration with and Effectiveness in Health Care and Public Health in the United States

Observational Analysis of a Generalized, Health Plan-led Community Health Worker Intervention in Medicaid

Promoting High-Value Care through Telehealth

Home-Based Primary Care Interventions

Providing Primary Care to Homebound Patients: UCSF Health's Care at Home Program

A Systematic Review of Primary Care and Payment Models on Emergency Department Use in Patients Classified as High Need, High Cost

‘Eyes in The Home’: ACOs Use Home Visits to Improve Care Management, Identify Needs, And Reduce Hospital Use

Complex Care Models to Achieve Accountable Care Readiness: Lessons from Two Community Hospitals

Bending the Spending Curve: The Role of Care Management in a Pioneer ACO

CareMore: Improving Outcomes and Controlling Health Care Spending for High-Needs Patients

Hennepin Health: A Care Delivery Paradigm for New Medicaid Beneficiaries