During the COVID-19 pandemic, Cityblock Health implemented a virtually integrated care management model to maintain continuity of care for patients with complex needs.
Primary care and alternative payment models that reduce emergency department use and increase access to care for high-need populations share core components for success.
Home-based program provided by a community health and social worker reduces acute care use and improves care for older adults with complex health and social needs.
Guidance on partnering with community-based organizations to provide services such as meal delivery and transportation for dually eligible individuals.
Home-based intensive care model for Medicaid and dually eligible enrollees with complex needs led to positive health outcomes and reduced acute care spending, particularly for individuals with a behavioral health diagnosis.
Use of machine learning clustering algorithms revealed 30 distinct subgroups of patients among high-risk veterans, indicating a need for tailored approaches to health care.
Analysis of recent and projected growth of expanded supplemental benefits offered by Medicare Advantage plans — such as meals, transportation, and in-home support services.
Details funding opportunities and successful approaches in the adoption of evidence-based health promotion and disease prevention programs within community-based organizations.
Identifies opportunities to strengthen integrated programs to improve care and support positive health outcomes for dually eligible individuals both during and beyond the pandemic.