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...
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...
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...
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...
Many older adults experience loneliness, which can lead to harmful impacts on mental as well as physical health. This literature review evaluated the effectiveness of published studies of...
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...
Project ECHO (Extension for Community Health Outcomes) virtually connects specialists with community-based providers to help improve patient care management. This evaluation of the ECHO Care pilot...
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...
A telephone-based social needs screening, referral, and navigation program that focused on patients with predicted high utilization within the Kaiser Permanente Southern California health system...
This resource describes and analyzes the different professional compositions of care management programs. Based on a national survey of clinicians caring for complex populations, nearly 40 percent of...
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 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...