"1" Resources

This resource is a study evaluating an alternative in-hospital assessment to determine the need for continuing care after discharge.

This resource is a study undertaken to understand the experiences of older adults living in community settings with multiple chronic conditions.

This resource builds on the seminal Home Alone study, the first national examination at how family caregivers manage medical and nursing tasks. Major findi

This resource describes four care management models that ACOs are using for individuals with complex needs.

This resource is a series of four videos (each roughly 12 minutes long) about how to transform care for people with involved disabilities according to the “independent living” mod

This resource, the Partnership Evaluation Tool, is intended to help organizations assess readiness to engage in successful value-based partnerships.

This resource provides an overview of a quality-improvement intervention focused on communication with patients with advanced cancer. 

This resource describes the 7-Day Pledge program to reduce readmissions by increasing access to timely primary care appointments after hospitalization.

This resource offers a variety of materials about “personas” for different segments of the high-need patient population.

Based on a review of the evidence, the Quick Reference Guide to Promising Care Models offers summary information on 2

This resource evaluates the impact of an interprofessional case conference approach in an academic primary care clinic.

This resource provides an evaluation of a health system’s outpatient complex case management (OPCM) program and examines whether OPCM lowers service utilization and he