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...
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...
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 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 shares 10 questions that California’s Medicaid managed care plans are now required to ask patients about their social and functional needs. These questions could serve as a model for...
This resource, the Accountable Care Atlas, is intended to help health care delivery systems identify and prioritize the competencies needed under risk-based payment. Experts agree that value-based...
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 proposes a framework to help guide the development of programs for populations with complex needs. While medical drugs and devices go through a well-established, rigorous development...
To help improve care for people with multiple chronic conditions, the U.S. Department of Health and Human Services has developed the Multiple Chronic Conditions Education and Training Framework to...
The Commonwealth Fund surveyed patients with complex needs from June to September of 2016, and an analysis of the results reveals that the health care system is failing to meet these patients’ needs...
This resource analyzes nationwide 2014 ED data across 13 geographically dispersed US states. Findings include: For ED visits covered by Medicaid, high-need, high-cost patients were on average older...