How High-Need Patients Experience Health Care in the United States This 2016 survey reveals that the health care system is failing people with complex needs Brief/Report December 2016
The Business Case for Community Paramedicine: Lessons from Commonwealth Care Alliance’s Pilot Program Cost considerations for the expansion of mobile integrated health care and community paramedicine programs. Case Example December 2016
The Return on Investment (ROI) Calculator: The Business Case and Person-Centered Care A calculator that can help build and present business case for serving adults with complex needs. Implementation Tool November 2016
Hennepin Health: A Care Delivery Paradigm for New Medicaid Beneficiaries By closing gaps in care, a safety-net ACO has reduced medical costs for Medicaid patients with complex needs. Case Example October 2016
New Models of Primary Care Workforce and Financing: Case Example #1: Stanford Coordinated Care Stanford Coordinated Care provides university employees with complex health needs better care at a lower cost Case Example October 2016
What Matters Most: Essential Attributes of a High-Quality System of Care for Adults with Complex Care Needs Experts describe how delivery systems can effectively serve adults with complex needs. Brief/Report September 2016
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
Tailoring Complex Care Management, Coordination, and Integration for High-Need, High-Cost Patients Improving care for high-need, high-cost patients is a key lever to decrease national health spending. 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
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
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
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
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
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
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