Resources

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 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 reviews best practices in care management contracting based on in-depth interviews with organizations that operate sustainable, effective programs for patients with complex needs. The...
This resource is a guide for payer and provider organizations to invest in social determinants of health (SDOH) and integrate them into their core business model. Few health care organizations have...
This resource is a Disability-Competent Care Self-Assessment Tool. It was developed to help health plans and health systems evaluate their own ability to meet the needs of adults with functional...
This resource reviews the case for segmenting patients with complex needs and different ways of segmenting, as well as challenges and limitations. The high-need, high-cost population is heterogeneous...