Health Care Hotspotting — A Randomized, Controlled Trial Randomized controlled trial of a care management intervention offers important lessons for the field of complex care. Peer-Reviewed Article 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
Quick Reference Guide to Promising Care Models This resource is an updated quick reference guide to promising models for people with complex needs. Brief/Report February 2019
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
Ten Questions to Better Understand and Serve Your Complex Care Population California is asking Medicaid patients these ten questions about social and functional needs. Brief/Report April 2018
The CHRONIC Care Act of 2018: Advancing Care for Adults with Complex Needs A brief summarizes what you need to know about the new Chronic Care Act. Brief/Report March 2018
Complex Care Models to Achieve Accountable Care Readiness: Lessons from Two Community Hospitals Case studies of two community hospitals show how to advance accountable care. Case Example March 2018
Effective Care for High-Need Patients: Opportunities for Improving Value, Outcomes and Health The National Academy of Medicine offers a synthesis of the evidence for improving care for high-needs patients. Brief/Report June 2017
Medicaid Managed Care Best Practices Compendium This resource collects the most innovative initiatives in Medicaid managed care that emerge each year. Brief/Report January 2017
The Care Transitions Intervention The Care Transitions Intervention was co-designed with patients and evaluated using randomized trials. Implementation Tool November 2016
Guided Care: A Structured Approach to Providing Comprehensive Primary Care for Complex Patients Guided Care is designed to strike a balance between telephone-based and interdisciplinary team-based care management programs. Case Example October 2016
Home-Based Care Program Reduces Disability and Promotes Aging in Place Difficulty with activities of daily living is a major cost driver in health care that is typically overlooked. Peer-Reviewed Article 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
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
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
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
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
Overview of Segmentation of High-Need, High-Cost Patient Population There are many promising strategies to segment individuals with complex needs. Here is one conceptual framework. Implementation Tool January 2016