Person-centered preferences can inform approaches to advanced illness care

Telemedicine may expand access to acute illness care and reduce emergency department visits for older adults.

Patients with a history of high health care utilization may be a good target for a care transition intervention

This 2016 survey reveals that the health care system is failing people with complex needs

Stanford Coordinated Care provides university employees with complex health needs better care at a lower cost

Difficulty with activities of daily living is a major cost driver in health care that is typically overlooked.

Cost considerations for the expansion of mobile integrated health care and community paramedicine programs.

Analysis of care models that serve Medicare-only individuals detailing policy barriers to providing uncovered services and supports and proposed strategies to address them.

The composition of teams varies depending on state staffing requirements and community resources.

Trauma-informed care can improve patient engagement and treatment adherence while reducing costs.

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.