Resources

This resource identifies challenges faced by older adults from racial and ethnic minorities, and proposes several strategies to address them.

This resource is a toolkit highlighting innovative care coordination strategies used by Medicare ACOs.

This resource is a toolkit for identifying patients with various physical, functional, emotional, social, and spiritual needs.

This resource is a study evaluating an alternative in-hospital assessment to determine the need for continuing care after discharge.

This resource is a study undertaken to understand the experiences of older adults living in community settings with multiple chronic conditions.

This resource provides an evaluation of a health system’s outpatient complex case management (OPCM) program and examines whether OPCM lowers service utilization and he

This resource assesses the characteristics and health care utilization of high-cost patients and compares high-cost patients across payers and countries, based on a systemat

This resource describes a study assessing the effects of patient activation and engagement strategies on patient-reported outcomes for patients with diabetes and/or cardiovascular

This resource analyzes the drivers of cost for Medicare-Medicaid beneficiaries, particularly looking at the differences between persistent and transient high costs.

This resource describes observations about root causes of high care utilization that emerged from a four-year intervention in a large population of patients with complex needs.

This resource is a Disability-Competent Care Self-Assessment Tool.

A retrospective cohort study examined the health care utilization of a group of patients in Memphis, Tennessee who met the enrollment criteria for the SafeMed Program, a care transitions program fo