Resources

Despite mounting evidence for community health workers (CHWs) and peer providers improving health outcomes, the expansion of the community-based workforce in the health care system has been limited...
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...
The Return-on-Investment (ROI) Calculator for Partnerships to Address the Social Determinants of Health, developed by The Commonwealth Fund, is designed to help support successful financial...
This analysis compared Medicare Advantage (MA) enrollees’ demographic, socioeconomic, and clinical characteristics plus health care utilization, spending, and quality of care in 2012 and 2015, and...
Cityblock Health provides care to populations with high rates of social, behavioral, and health risk factors, many of whom are at higher risk for complications from COVID-19. Cityblock developed a...
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...
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...
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...
While high-cost patients include diverse subgroups with varying clinical and social needs, efforts to improve the efficiency of care and target interventions have been limited by the lack of knowledge...
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...
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...
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...