All Resources

Development of a Care Guidance Index Based on What Matters to Patients

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


Serious Illness Conversation Guide

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


State Strategies: Value-Based Payment for Medicaid Populations with Complex Care Needs

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


Effective Care for High-Need Patients: Opportunities for Improving Value, Outcomes and Health

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).

Bridging the Silos of Service Delivery for High-Need, High-Cost Individuals

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

Improving Care for High-Need, High-Cost Medicare Patients

This report recommends policy changes so that Medicare can pay for non-medical supports and services, such as meal delivery, transportation, and case management, to improve outcomes and lower costs

Systematic Review of Programs Treating High-Need and High-Cost People With Multiple Chronic Diseases or Disabilities in the United States, 2008–2014

This systematic review, which includes 27 studies across five models of care, evaluates the effectiveness of programs to improve care and lower cost for people with multiple chronic conditions or d

Tailoring Complex Care Management for High-Need, High-Cost Patients

This viewpoint article argues that policy can play an important role in improving outcomes for people with complex needs in the US, and it makes several recommendations for the current federal admi

Disruptive Models in Primary Care: Caring for High-Needs, High-Cost Populations

This resource offers a clinical vignette highlighting the challenges of caring for persons with complex needs, followed by descriptions of two approaches for managing these populations, and finally

House Calls: California Program For Homebound Patients Reduces Monthly Spending, Delivers Meaningful Care

This resource offers a description and evaluation of House Calls, a well-established program in Southern California that provides home-based care for high-risk frail and homebound older adults.

So Many Options, Where Do We Start? An Overview of the Care Transitions Literature

This resource provides a systematic review of transitional care interventions that reported hospital readmission as an outcome.

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

This resource is a case study of CareMore, a Medicare Advantage plan and medical provider based in Cerritos, California, that serves 130,000 enrollees in Medicare and Medicaid managed care plans ac