Displaying 481 - 500 of 532

Delivery System Reform: Improving Care for Individuals Dually Eligible for Medicare and Medicaid

Dual-eligible beneficiaries are often more sick, have greater functional and cognitive impairments, and require more care coordination.

Brief/Report

September 2016

A Systematic Review of Evidence for the Clubhouse Model of Psychosocial Rehabilitation

“Clubhouses” for people with serious mental illness are effective at promoting employment, reducing hospitalizations, and improving quality of life.

Peer-Reviewed Article

August 2016

High-Need, High-Cost Patients: Who Are They and How Do They Use Health Care?

There is considerable variation in use and spending among high-need adults, suggesting this population should be segmented into subgroups.

Brief/Report

August 2016

Aging Gracefully: The PACE Approach to Caring for Frail Elders in the Community

Reviews lessons from the Program of All-Inclusive Care for the Elderly on serving high-need populations in community settings.

Case Example

August 2016

The Hospital at Home Model: Bringing Hospital-Level Care to the Patient

The program offers a lower-cost alternative to the hospital for patients who can be safely treated at home.

Case Example

August 2016

Improving Population Health Management Strategies: Identifying Likely Users of Avoidable Costly Care

Assessing patients’ activation levels can help identify those at risk for poor health outcomes and utilization of avoidable, costly care.

Peer-Reviewed Article

August 2016

The Core of Care Management: The Role of Authentic Relationships in Caring for Patients with Frequent Hospitalizations

This study links “authentic healing relationships” with patient motivation and active health management.

Peer-Reviewed Article

August 2016

Project ECHO’s Complex Care Initiative: Building Capacity to Help “Superutilizers”

Interdisciplinary teams provide support for Medicaid beneficiaries with mental illnesses, addictions, and other needs.

Case Example

August 2016

Leveraging the Social Determinants of Health: What Works?

This literature review assesses the impact of social service interventions.

Peer-Reviewed Article

August 2016

Bringing Primary Care Home: The Medical House Call Program at MedStar Washington Hospital Center

A home-based primary care program decreases costs and utilization for high-risk Medicare enrollees in Washington D.C.

Case Example

July 2016

Person-Centered Care: The Business Case

Federal policy changes have made PCC models of care more financially viable.

Brief/Report

June 2016

Payment to Promote Sustainability of Care Management Models for High-Need, High-Cost Patients

Provider incentives must be based on Triple Aim outcomes.

Brief/Report

May 2016

Taxonomy of Long-Term Services and Supports Integration

A standardized tool to assess where along a continuum a program lies with regard to components of integration.

Implementation Tool

April 2016

Characteristics of Hospital and Emergency Care Super-Utilizers with Multiple Chronic Conditions

Patients with a history of high health care utilization may be a good target for a care transition intervention

Peer-Reviewed Article

April 2016

Key Components for Successful LTSS Integration: Lessons from Five Exemplar Plans

Successful long-term services and supports programs have a single point of accountability, such as a care manager.

Brief/Report

April 2016

Key Ingredients for Successful Trauma-Informed Care Implementation

Trauma-informed care can improve patient engagement and treatment adherence while reducing costs.

Brief/Report

April 2016

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

A systemic review of transitional care interventions reporting hospital readmission

Peer-Reviewed Article

March 2016

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

A study of five programs identified key factors that support collaboration among community-based health and social services.

Peer-Reviewed Article

March 2016

Adding a Measure of Self-Management Capability to Risk Assessment Can Improve Prediction of High Costs

Less “activated” patients are more likely to benefit from care coordination.

Peer-Reviewed Article

March 2016

Interventions for Patients with Multimorbidity in Primary Care and Community Settings

A review of the evidence suggests it's difficult to improve outcomes for people with multimorbidity.

Peer-Reviewed Article

March 2016

All Resources

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State

Delivery System Reform: Improving Care for Individuals Dually Eligible for Medicare and Medicaid

A Systematic Review of Evidence for the Clubhouse Model of Psychosocial Rehabilitation

High-Need, High-Cost Patients: Who Are They and How Do They Use Health Care?

Aging Gracefully: The PACE Approach to Caring for Frail Elders in the Community

The Hospital at Home Model: Bringing Hospital-Level Care to the Patient

Improving Population Health Management Strategies: Identifying Likely Users of Avoidable Costly Care

The Core of Care Management: The Role of Authentic Relationships in Caring for Patients with Frequent Hospitalizations

Project ECHO’s Complex Care Initiative: Building Capacity to Help “Superutilizers”

Leveraging the Social Determinants of Health: What Works?

Bringing Primary Care Home: The Medical House Call Program at MedStar Washington Hospital Center

Person-Centered Care: The Business Case

Payment to Promote Sustainability of Care Management Models for High-Need, High-Cost Patients

Taxonomy of Long-Term Services and Supports Integration

Characteristics of Hospital and Emergency Care Super-Utilizers with Multiple Chronic Conditions

Key Components for Successful LTSS Integration: Lessons from Five Exemplar Plans

Key Ingredients for Successful Trauma-Informed Care Implementation

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

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

Adding a Measure of Self-Management Capability to Risk Assessment Can Improve Prediction of High Costs

Interventions for Patients with Multimorbidity in Primary Care and Community Settings