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

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.

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

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

A retrospective cohort study examined the health care utilization of a group of patients in Memphis, Tennessee who met the enrollment criteria for the SafeMed Program, a care transitions program fo

Telemedicine has the potential to expand access to acute illness care and prevent ED visits for older adults.

The Commonwealth Fund surveyed patients with complex needs from June to September of 2016, and an analysis of the results reveals that the health care system is failing to meet these patients’ need

This resource explores the value of five different home visit program models.

This resource identifies and describes person-centered preferences that can inform approaches to advanced illness care.

This resource summarizes a descriptive study of the Health Resilience Program (HRP) in Oregon, a program designed to address the needs of high-risk Medicaid and Medicare patients and reduce costs.

The problem of the high cost of health care has centered on reducing spending among the patients who use the most health care services.

Denver Health received a Centers for Medicare and Medicaid Innovation Award to develop an intensive outpatient clinic (IOC) to improve care and lower costs for patients with complex needs.