Resources

Care transition interventions can be difficult to successfully implement, but using an evidence-based framework to incorporate stakeholder feedback can help identify barriers to effectiveness...
Despite mounting evidence for community health workers (CHWs) and peer providers improving health outcomes, the expansion of the community-based workforce in the health care system has been limited...
Although health care systems commonly refer individuals with unmet social needs to social service agencies, in some cases, these agencies may not have the capacity to provide adequate assistance. This...
To improve health outcomes and reduce health care costs and utilization for people with complex needs, it is important to understand the underlying social and behavioral issues that may be driving...
Adventist Health Clear Lake, a health system in rural California, initiated a cross-sector collaboration between rural service providers and community agencies to more effectively address the needs of...
This resource describes a study of five plans that integrate LTSS into care. The study examined differences in medical utilization by beneficiaries, compared to a population with a similar level of...
This resource provides a framework for understanding the nature and extent of integration in programs that integrate LTSS with medical care and behavioral health. This taxonomy is a standardized tool...
This resource describes an effort to apply a learning health systems approach to reducing ED utilization. A learning health system focuses on improving people’s health at scale through continuous...
This resource, the Partnership Evaluation Tool, is intended to help organizations assess readiness to engage in successful value-based partnerships. It can be used to assess potential partners or for...
This resource describes the strategies employed by ACOs that have comprehensive care management programs for complex patients. This report is from the six-foundation collaborative and is based on...
This resource describes a study of the Johns Hopkins Community Health Partnership (J-CHiP), which was created as a regional approach to health care transformation in Baltimore, Maryland. J-CHiP...
This resource describes a randomized quality improvement trial that assessed whether augmenting usual primary care with team-based intensive management lowers utilization and costs for high-risk...