Resources

Health care organizations are increasingly partnering with Area Agencies on Aging (AAAs) to provide social needs support for older adults in the community who are identified with high health risks...
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...
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...
Interventions targeting frequent emergency department (ED) users are increasingly common, but many are developed with limited understanding of this population’s comprehensive use of medical and social...
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 guidelines for implementing Special Supplemental Benefits for the Chronically Ill (SSBCI) in a manner that improves health care for chronically ill Medicare beneficiaries. The...
This resource used national survey data from physician practices and ACOs, paired with qualitative interviews, to learn about home visiting programs. ACO practices were more likely to report using...
This resource identifies challenges faced by older adults from racial and ethnic minorities, and proposes several strategies to address them. Older adults from racial and ethnic minorities face...
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 is a toolkit highlighting innovative care coordination strategies used by Medicare ACOs. ACOs use a variety of methods to coordinate and manage the care of their populations, including...
This resource is a study evaluating an alternative in-hospital assessment to determine the need for continuing care after discharge. In the UK, a long and complicated Continuing Health Care (CHC)...
This resource is a study undertaken to understand the experiences of older adults living in community settings with multiple chronic conditions. Common themes for study participants included depending...