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 shares 10 questions that California’s Medicaid managed care plans are now required to ask patients about their social and functional needs.

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

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’ need

This resource analyzes nationwide 2014 ED data across 13 geographically dispersed US states. Findings include:

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.

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.

This resource examines health care spending and use of services among adults with high needs, defined as people who have three or more chronic diseases and a functional limitation.

This resource reviews Commonwealth Fund survey data focused on high-need adults ages 65 and older in nine countries — Australia, Canada, France, Germany, the Netherlands, Norway, Sweden, Switzerlan