Four key interventions are essential to create an age-friendly system of care. If care providers consistently do these four things for every older adult, every time, across care settings, we believe we will save lives and avoid harm.

Most care delivery systems don’t proactively identify and meaningfully engage or support family caregivers in visits or care plans. Jennifer Wolff, PhD, a gerontologist and health services researcher shares how complex care programs can better engage families in care for patients.

How can you make the most of your community health needs assessments? Here are three tips to help you turn your assessments into action.

Christine Vogeli shares insights about how Partners HealthCare launched the Integrated Care Management Program, how the program is managed, and her advice for others getting started with care for people with complex needs.

Christine Vogeli, PhD, Director of Evaluation and Research at Partners HealthCare Center for Population Health, shares how their Integrated Care Management Program uses predictive analytics to identify patients to enroll.

Patients with complex needs are often described as the five percent of patients who account for 50 percent of health care spending. Behind that often cited statistic are the individuals who make up that population — all of whom have their own stories and needs.

Shares insights and guidance on how to use findings from a recently released report from the National Academy of Medicine, which explores the key attributes of patients with complex needs and how to improve care for this patient population.

Marit Tanke, MD, PhD, a Commonwealth Fund Harkness Fellow, walks us through her research to analyze high-need, high-cost patients across four countries — including her methodology, how costly these patients are, who these patients are, and how they use health care.

Jose Figueroa, MD, a hospitalist at Brigham and Women’s Hospital and a researcher at Harvard School of Public Health and Harvard Medical School, has been researching who patients with complex needs are and helped created a model for identifying population segments within this broad category.