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...
The number of individuals living with dementia is steadily increasing, and family caregivers for individuals with dementia frequently experience challenges with maintaining their own physical...
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 describes the Great Plains Senior Services Collaborative, an initiative to improve health and quality of life for rural seniors. Populations of rural seniors face significant challenges...
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 is a toolkit to help payers and providers understand how home-based primary care (HBPC) improves quality and reduces costs for seriously ill and home-limited older adults. HBPC providers...
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, 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...
Based on a review of the evidence, the Quick Reference Guide to Promising Care Models offers summary information on 28 programs for adults with complex needs, specifically: Target population and...