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
The Effects of Home-Based Primary Care on Medicare Costs at Spectrum Health/Priority Health from 2012-Present: A Matched Cohort Study A home-based primary care program led to reduced medical costs for frail elderly patients, primarily due to lower spending at end-of-life. Peer-Reviewed Article March 2018
Managing Effectively in Complex Chronic Care Markets This resource provides a road map for health plans to improve Medical Loss Ratio. Peer-Reviewed Article February 2018
Operation and Challenges of Home-Based Medical Practices in the US: Findings from Six Aggregated Case Studies Strategies for home-based primary care practices to improve efficiency and support program growth based on qualitative research. Peer-Reviewed Article January 2018
What Works in Integrated Care Programs for Older Adults with Complex Needs? A Realist Review A literature review describes the most important success factors for integrated care programs. Peer-Reviewed Article October 2017
Community Health Worker Support for Disadvantaged Patients with Multiple Chronic Diseases: A Randomized Clinical Trial This resource describes the benefits of community health workers for people with multiple chronic conditions. Peer-Reviewed Article October 2017
Building Complex Care Programs: A Road Map for States This guide for state leaders offers lessons about state-level approaches to complex care. Implementation Tool October 2017
Designing a Health Care System for Patients with Complex Needs: Ten Recommendations for Policymakers An international expert group offers ten policy recommendations and profiles of innovative care models. Brief/Report September 2017
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
Integrating Health Care for High-Need Medicaid Beneficiaries With Serious Mental Illness and Chronic Physical Health Conditions at Managed Care, Provider, and Consumer Levels This resource describes the value of navigators for Medicaid beneficiaries with mental illness. Peer-Reviewed Article June 2017
Bending the Spending Curve: The Role of Care Management in a Pioneer ACO ACOs have lowered costs for high-need patients through care management programs focused on modifiable spending. Peer-Reviewed Article May 2017
Caregiver Integration during Discharge Planning of Older Adults to Reduce Resource Utilization: A Systematic Review and Meta-Analysis of Randomized Controlled Trials Including caregivers in the discharge planning process reduces the risk of hospital readmission for older adults. Peer-Reviewed Article April 2017
Preventing Hospitalization with Veterans Affairs Home-Based Primary Care: Which Individuals Benefit Most? Home-based primary care program reduced hospitalizations for older adults with diabetes, especially those with higher levels of medical complexity. Peer-Reviewed Article March 2017
CareMore: Improving Outcomes and Controlling Health Care Spending for High-Needs Patients CareMore’s business model identifies high-risk patients and surrounds them with coordinated services Case Example March 2017
Innovative Home Visit Models Associated with Reductions in Costs, Hospitalizations, and Emergency Department Use Home visits can reach patients with complex needs before a higher level of care is needed Peer-Reviewed Article March 2017
Complex Care Program Development: A New Framework for Design and Evaluation A new framework outlines four steps to develop care management programs. Brief/Report March 2017
Care Management Plus: Strengthening Primary Care for Patients with Multiple Chronic Conditions A program to help clinics deliver comprehensive care may decrease mortality and hospitalization rates. Case Example 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
Intensive Outpatient Care Program Toolkit The staff position of care coordinator is crucial to success. Implementation Tool December 2016
The Care Transitions Intervention The Care Transitions Intervention was co-designed with patients and evaluated using randomized trials. Implementation Tool November 2016