People with Behavioral Health and Social Needs Resources

This resource describes a randomized controlled trial to evaluate the effects of a case management intervention called V1SAGES (Vulnerable Patients in Primary Care: Nurse Ca

This resource describes an effort to apply a learning health systems approach to reducing ED utilization.

This resource is a toolkit highlighting innovative care coordination strategies used by Medicare ACOs.

This resource is a toolkit for identifying patients with various physical, functional, emotional, social, and spiritual needs.

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

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