Resources

Interventions targeting frequent emergency department (ED) users are increasingly common, but many are developed with limited understanding of this population’s comprehensive use of medical and social...
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 is a study evaluating an alternative in-hospital assessment to determine the need for continuing care after discharge. In the UK, a long and complicated Continuing Health Care (CHC)...
This resource provides an evaluation of a health system’s outpatient complex case management (OPCM) program and examines whether OPCM lowers service utilization and health care costs. U.S. health...
This resource assesses the characteristics and health care utilization of high-cost patients and compares high-cost patients across payers and countries, based on a systematic review of studies in...
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 analyzes the drivers of cost for Medicare-Medicaid beneficiaries, particularly looking at the differences between persistent and transient high costs. We know surprisingly little about...
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 describes observations about root causes of high care utilization that emerged from a four-year intervention in a large population of patients with complex needs. In 2012, Mercy Health...
This resource describes the Complex Care Map (CCM ©), a tool that addresses fragmentation in the health system and helps providers understand the patient’s story. It was implemented in a quality...