Resources

While health care quality improvement teams often involve clinical staff, these teams would benefit from the inclusion of community health workers (CHWs), who can provide insights into patient needs...
This resource is a toolkit to help payers and providers understand how home-based primary care (HBPC) improves quality and reduces costs for seriously ill and home-limited older adults. HBPC providers...
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 series of four videos (each roughly 12 minutes long) about how to transform care for people with involved disabilities according to the “independent living” model. The first video...
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 resource provides guidance for state leaders in establishing and advancing complex care programs. Since 2013, the National Governors Association Center for Best Practices (NGA Center) Health...
This resource is a toolkit that describes strategies for states to reform their Medicaid LTSS systems. Medicaid is the leading payer for LTSS systems, which enable more than 12 million people to meet...
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...
This resource describes the CTI®, which provides patients and caregivers with the skills and tools necessary for individuals to assume a more active role in their care. The CTI® was co-designed with...