Displaying 21 - 40 of 52

Operational Guide to Identify, Understand, and Treat High-Need Patients

Offers a practical framework for safety-net health systems to better identify and segment patients with complex needs, and tailor care models to meet their needs.

Implementation Tool

September 2020

Age-Friendly Health Systems: Guide to Using the 4Ms in the Care of Older Adults

Step-by-step guide with robust tools for health systems to apply the 4Ms framework to deliver age-friendly, evidence-based care for older adults.

Implementation Tool

July 2020

Rural Community Paramedicine Toolkit

Toolkit offers health care stakeholders in rural areas with practical information to support the design, implementation, and evaluation of community paramedicine programs.

Implementation Tool

June 2020

Integrating Community Health Workers on Quality Improvement Teams: Lessons from the Field

Tips on integrating community health workers into quality improvement teams to address patients’ social needs.

Implementation Tool

January 2020

Person-Centered Engagement at the Organizational Level

Contains strategies, tips, and case studies to assist health care stakeholders in building meaningful, person-centered engagement in their organizations.

Implementation Tool

January 2020

A Practical Guide to Expanding Home-Based Primary Care with Telehealth

Tools, tips, and vignettes for incorporating telehealth into home-based primary care models.

Implementation Tool

December 2019

Housing and the Role of Hospitals

Guide for hospitals to address housing instability by understanding the evidence, evaluating different approaches, and exploring case studies of health system-led programs.

Implementation Tool

September 2019

HOUSED BEDS: A Clinical Tool for Taking a History on an Unsheltered Homeless Patient

A tool helps providers capture essential information when interviewing people experiencing unsheltered homelessness to support effective treatment planning.

Implementation Tool

July 2019

A Turning Point in Medicare Policy: Guiding Principles for New Flexibility Under Special Supplemental Benefits for the Chronically Ill

How to implement the new Medicare benefits.

Implementation Tool

July 2019

Home-Based Primary Care Resources: A Toolkit for Health Partners

This toolkit details the benefits of home-based primary care to help providers demonstrate the need for these programs.

Implementation Tool

June 2019

Addressing Health Equity through Health and Housing Partnerships

Strategies for health centers and supportive housing providers to advance health equity by partnering to provide person-centered care.

Implementation Tool

May 2019

Home-Based Primary Care Fall Prevention and Management Toolkit

Shares best practices and screening tool options to identify and care for home-based primary care patients with potential fall risks.

Implementation Tool

April 2019

Identifying and Designing the Right Care Management Program: Insights from ACOs

Four care management models for ACOs.

Implementation Tool

April 2019

State Pathways to Integrated Care: Exploring Options for Medicare-Medicaid Integration

Outlines steps states can take to advance Medicare-Medicaid integration depending on policy goals, internal capacity, and delivery system structures.

Implementation Tool

April 2019

Health Care Transformation Task Force Value Partnership Evaluation Tool

A tool for assessing readiness for value-based partnerships.

Implementation Tool

March 2019

Care Coordination Toolkit

How ACOs can improve care coordination.

Implementation Tool

March 2019

High-Need, High-Cost Personas

An in-depth overview of different personas.

Implementation Tool

February 2019

Blueprint for Complex Care: Advancing the Field of Care for Individuals with Complex Health and Social Needs

This resource outlines the current state of complex care and recommendations for the future.

Implementation Tool

December 2018

The ROI Calculator for Partnerships to Address the Social Determinants of Health

A web-based financial tool that helps navigate partnerships between health care organizations and social service organizations.

Implementation Tool

August 2018

Care Management Contracting for Complex Populations: Best Practices and Tools

This resource offers guidance on contracting for populations with complex needs.

Implementation Tool

July 2018

All Resources

Topics

Populations

Audiences

Content Types

State

Operational Guide to Identify, Understand, and Treat High-Need Patients

Age-Friendly Health Systems: Guide to Using the 4Ms in the Care of Older Adults

Rural Community Paramedicine Toolkit

Integrating Community Health Workers on Quality Improvement Teams: Lessons from the Field

Person-Centered Engagement at the Organizational Level

A Practical Guide to Expanding Home-Based Primary Care with Telehealth

Housing and the Role of Hospitals

HOUSED BEDS: A Clinical Tool for Taking a History on an Unsheltered Homeless Patient

A Turning Point in Medicare Policy: Guiding Principles for New Flexibility Under Special Supplemental Benefits for the Chronically Ill

Home-Based Primary Care Resources: A Toolkit for Health Partners

Addressing Health Equity through Health and Housing Partnerships

Home-Based Primary Care Fall Prevention and Management Toolkit

Identifying and Designing the Right Care Management Program: Insights from ACOs

State Pathways to Integrated Care: Exploring Options for Medicare-Medicaid Integration

Health Care Transformation Task Force Value Partnership Evaluation Tool

Care Coordination Toolkit

High-Need, High-Cost Personas

Blueprint for Complex Care: Advancing the Field of Care for Individuals with Complex Health and Social Needs

The ROI Calculator for Partnerships to Address the Social Determinants of Health

Care Management Contracting for Complex Populations: Best Practices and Tools