Resources

Veterans frequently have complex medical, behavioral, and social needs, but often experience barriers in accessing health care services from the Department of Veterans Affairs (VA), the largest...
While community health worker (CHW) programs that serve low-income populations have demonstrated reductions in preventable acute care utilization, these programs often have limited funding. Developing...
Engaging patients in shared decision-making requires providers to integrate patient-identified goals into patient-provider communications. This qualitative study explored how high-need, high-cost...
When designing alternate payment models such as accountable care organizations (ACOs) to improve care for vulnerable populations, it is important to understand the impact that social determinants of...
This resource describes a care guidance index based on what matters to patients. Identifying a high-risk subgroup is a strategy for chronic care management. However, common methods of assessing risk...
This study examined five programs that serve patients with complex needs through medical and non-medical services. Authors created a framework to illustrate the foundational factors that encourage...