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...
While community health worker (CHW) programs that serve low-income populations have demonstrated reductions in preventable acute care utilization, these programs often have limited funding. Developing...
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...
Integrated primary care teams have demonstrated positive impacts on patient care, but less is known about the impact of including social workers on these teams. This study evaluated the addition of...
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...
Adventist Health Clear Lake, a health system in rural California, initiated a cross-sector collaboration between rural service providers and community agencies to more effectively address the needs of...
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 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 a study of the Johns Hopkins Community Health Partnership (J-CHiP), which was created as a regional approach to health care transformation in Baltimore, Maryland. J-CHiP...
This resource describes a randomized quality improvement trial that assessed whether augmenting usual primary care with team-based intensive management lowers utilization and costs for high-risk...
This resource describes the evolution of complex care management targeting strategies in Community Care of North Carolina’s (CCNC) work with the statewide non-dual Medicaid population, culminating in...
This resource explores whether individuals’ levels of engagement in their care — referred to as “patient activation” — correlates with their use of services and status as “high need, high cost.”...