Resources

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...
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 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 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 an evaluation of a health system’s outpatient complex case management (OPCM) program and examines whether OPCM lowers service utilization and health care costs. U.S. health...
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 systematic review of studies in...
This resource analyzes the drivers of cost for Medicare-Medicaid beneficiaries, particularly looking at the differences between persistent and transient high costs. We know surprisingly little about...
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. In 2012, Mercy Health...
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...