Initial Recommendations to Improve the Financing of Long-Term Care
Well-designed federal policies can help meet the rising need.
Brief/Report
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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
What Matters Most: Essential Attributes of a High-Quality System of Care for Adults with Complex Care Needs
Experts describe how delivery systems can effectively serve adults with complex needs.
Brief/Report
High-Need, High-Cost Patients: Who Are They and How Do They Use Health Care?
There is considerable variation in use and spending among high-need adults, suggesting this population should be segmented into subgroups.
Brief/Report
How High-Need Patients Experience the Health Care System in Nine Countries
The U.S. had the highest rate of cost-related access problems.
Brief/Report
Attributes Common to Programs That Successfully Treat High-Need, High-Cost Individuals
Targeting is important, even within the high-need patients enrolled in the program.
Peer-Reviewed Article
Generating Hypotheses about Care Needs of High Utilizers: Lessons from Patient Interviews
This resource presents promising ideas for more effective modes of care for persons with complex needs.
Peer-Reviewed Article
The Hospital at Home Model: Bringing Hospital-Level Care to the Patient
The program offers a lower-cost alternative to the hospital for patients who can be safely treated at home.
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
The Care Transitions Intervention
The Care Transitions Intervention was co-designed with patients and evaluated using randomized trials.
Implementation Tool
Adding a Measure of Self-Management Capability to Risk Assessment Can Improve Prediction of High Costs
Less “activated” patients are more likely to benefit from care coordination.
Peer-Reviewed Article
Using Data to Better Serve the Most Complex Patients: Highlights from NGA’s Intensive Work with Seven States
The National Governors Association worked for two years to improve care and lower costs for Medicaid “super-utilizers.”
Brief/Report
Key Components for Successful LTSS Integration: Lessons from Five Exemplar Plans
Successful long-term services and supports programs have a single point of accountability, such as a care manager.
Brief/Report
Caring for High-Need, High-Cost Patients: What Makes for a Successful Care Management Program?
A comparison of 18 complex care management programs reveals best practices.
Brief/Report
Effective Management of High-Risk Medicare Populations
A three-pronged strategy can help manage care for Medicare beneficiaries.
Brief/Report
Six Features of Medicare Coordinated Care Demonstration Programs that Cut Hospital Admissions
A study showed that some programs reduced hospitalizations by 8 to 33 percent.
Peer-Reviewed Article
Emergency Department Super-Utilizer Programs: Rural Health Systems Analysis and Technical Assistance Project
This guide describes how to design, implement, and assess a program to reduce preventable ED use.
Implementation Tool
Persistent High Utilization in a Privately Insured Population
This resource takes a close look at individuals with complex needs who are privately insured.
Peer-Reviewed Article
Improving Care for People with Serious Illness Through Innovative Payer-Provider Partnerships
The benefits of, incentives for, and various models to deliver palliative care are described.
Implementation Tool
Person-Centered Care: The Business Case
Federal policy changes have made PCC models of care more financially viable.
Brief/Report