Resources

Complex care programs across the country use varied criteria to identify people with complex health and social needs and measure the effectiveness of subsequent interventions. Greater standardization...
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...
High-need, high-cost Medicaid patients enrolled in a 12-month complex care management program at CareMore Health in Memphis, Tennessee experienced reductions of 59 percent in inpatient utilization and...
A randomized controlled trial found that the “Camden Core Model,” a short-term care management program for individuals with complex health and social needs and multiple recent hospital admissions, did...
This resource describes a quasi-experimental study evaluating the effect of a transitional care program that involved rapid primary care follow-up for Medicaid and Medicare patients with complex needs...
Family caregivers are a critical part of the home- and community-based workforce for people with serious illness. This is particularly the case for veterans, who are often sicker than the general...
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 describes a randomized controlled trial to evaluate the effects of a case management intervention called V1SAGES (Vulnerable Patients in Primary Care: Nurse Case Management and Self...
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 describes the 7-Day Pledge program to reduce readmissions by increasing access to timely primary care appointments after hospitalization. Previous research suggests the important role of...
This resource evaluates the impact of an interprofessional case conference approach in an academic primary care clinic. This study was conducted at a primary care clinic at a VA medical center. The...