This resource describes the Complex Care Map (CCM ©), a tool that addresses fragmentation in the health system and helps providers understand the patient’s story.

This resource describes the Super Utilizer Project, a collaboration between an integrated health care organization and a baccalaureate school of nursing.


​​​​This resource describes a program in New Mexico that employs community health workers (CHWs) to address social determinants of health, as well as how that program was implemented and spread.

This resource contains profiles of nearly a hundred programs that target complex patients across 36 states and territories, including Puerto Rico and Washington, DC.


This resource proposes a framework to help guide the development of programs for populations with complex needs.


This resource examines the experience of providers with the Medicaid health home option, a provision of the Affordable Care Act.

To help improve care for people with multiple chronic conditions, the U.S.

This resource describes a care guidance index based on what matters to patients.


This resource provides step-by-step guidance for clinicians engaging in conversation with patients about serious illness.


This resource examines Medicaid payment reform strategies for populations who receive LTSS. It includes case studies of state programs in Tennessee, Minnesota, and Arizona. 


This resource is the product of a collaborative assessment on strategies for better serving high-need patients convened by the National Academy of Medicine (NAM).

This study examined five programs that serve patients with complex needs through medical and non-medical services.