Resources

Palliative care improves quality of life for both the patient and the family. It is appropriate at any age and at any stage of illness, and it can be provided along with curative treatment. Palliative...
A majority of mature accountable care organizations (ACOs) segment their high-need, high-cost (HNHC) population into smaller subgroups to better identify those with similar needs, employing a range 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 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 highlights a variety of prevention-focused programs, initiatives and strategies (plays) focused on the opioid use epidemic. The resource describes 11 plays that are supported by evidence...
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 toolkit for identifying patients with various physical, functional, emotional, social, and spiritual needs. Patients and families living with serious illness have a range of needs...
This resource describes four care management models that ACOs are using for individuals with complex needs. Care management programs can involve creating patient care plans, coordinating care across...
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 offers a variety of materials about “personas” for different segments of the high-need patient population. A persona helps depict the experiences, motivations, and goals of a group of...
This tool is a calculator designed to assist community-based organizations and their health care partners in creating financial arrangements to fund social services for patients with complex needs. It...
This resource examines three innovative models for treating patients with serious illness, developed by third-party firms that contract with Medicare Advantage plans. The financing structure of...