Resources

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 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...
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...
To inform the delivery of targeted care for the highest-need beneficiaries, this resource examines comorbidity patterns among Medicaid beneficiaries under 65 years old with disabilities. Key findings...
This resource describes opportunities to use digital health products for high-need, high-cost populations. It summarizes the results of the Super-Utilizer Health Innovation Challenge, run by the...
This resource provides an introduction to trauma‐informed care, describing how it can serve high‐need, high‐cost Medicaid populations. It includes three case studies of innovative programs and a chart...
This resource provides personas, which are character profiles aggregated from a collection of interviews with members of a population, for three subgroups of the high-need population. The personas...