Resources

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...
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...
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...
Approximately one in three Medicare beneficiaries is enrolled in a Medicare Advantage (MA) plan, and more than one third of these MA enrollees are classified as high need based on their chronic...
Incorporating patient self-reported data may allow health systems to more effectively identify specific groups of older adults with unique needs, thereby helping to inform the development of patient...
This resource identifies challenges faced by older adults from racial and ethnic minorities, and proposes several strategies to address them. Older adults from racial and ethnic minorities face...
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 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 is a study undertaken to understand the experiences of older adults living in community settings with multiple chronic conditions. Common themes for study participants included depending...