Resources

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...
Complex care programs across the country use varied criteria to identify people with complex health and social needs and measure the effectiveness of subsequent interventions. Greater standardization...
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...
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...
High-need, high-cost Medicaid patients enrolled in a 12-month complex care management program at CareMore Health in Memphis, Tennessee experienced reductions of 59 percent in inpatient utilization and...
Project ECHO (Extension for Community Health Outcomes) virtually connects specialists with community-based providers to help improve patient care management. This evaluation of the ECHO Care pilot...
A randomized controlled trial found that the “Camden Core Model,” a short-term care management program for individuals with complex health and social needs and multiple recent hospital admissions, did...
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...
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...
A telephone-based social needs screening, referral, and navigation program that focused on patients with predicted high utilization within the Kaiser Permanente Southern California health system...
This resource describes a quasi-experimental study evaluating the effect of a transitional care program that involved rapid primary care follow-up for Medicaid and Medicare patients with complex needs...