Resources

To improve the quality and value of care and target interventions most effectively, it is important to understand the distinction between individuals with complex health and social needs who have...
The Return-on-Investment (ROI) Calculator for Partnerships to Address the Social Determinants of Health, developed by The Commonwealth Fund, is designed to help support successful financial...
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...
Cityblock Health provides care to populations with high rates of social, behavioral, and health risk factors, many of whom are at higher risk for complications from COVID-19. Cityblock developed a...
Effective patient-centered case management interventions can potentially improve health and social outcomes for individuals experiencing homelessness or housing instability. This literature review...
While high-cost patients include diverse subgroups with varying clinical and social needs, efforts to improve the efficiency of care and target interventions have been limited by the lack of knowledge...
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...
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 highlights a variety of prevention-focused programs, initiatives and strategies (plays) focused on the opioid use epidemic. The resource describes 11 plays that are supported by evidence...
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 study evaluating an alternative in-hospital assessment to determine the need for continuing care after discharge. In the UK, a long and complicated Continuing Health Care (CHC)...
This resource is a study undertaken to understand the experiences of older adults living in community settings with multiple chronic conditions. Common themes for study participants included depending...