Resources

This resource provides guidelines for implementing Special Supplemental Benefits for the Chronically Ill (SSBCI) in a manner that improves health care for chronically ill Medicare beneficiaries. The...
This resource provides a framework for understanding the nature and extent of integration in programs that integrate LTSS with medical care and behavioral health. This taxonomy is a standardized tool...
This resource describes four care management models that ACOs are using for individuals with complex needs. Care management programs can involve creating patient care plans, coordinating care across...
This resource, the Partnership Evaluation Tool, is intended to help organizations assess readiness to engage in successful value-based partnerships. It can be used to assess potential partners or for...
This tool is a calculator designed to assist community-based organizations and their health care partners in creating financial arrangements to fund social services for patients with complex needs. It...
This resource reviews best practices in care management contracting based on in-depth interviews with organizations that operate sustainable, effective programs for patients with complex needs. The...
This resource is a guide for payer and provider organizations to invest in social determinants of health (SDOH) and integrate them into their core business model. Few health care organizations have...
This resource, the Accountable Care Atlas, is intended to help health care delivery systems identify and prioritize the competencies needed under risk-based payment. Experts agree that value-based...
This resource provides step-by-step guidance for clinicians engaging in conversation with patients about serious illness. The basic steps are: set up the conversation; assess understanding and...
This resource offers a structured improvement process for redesigning care for people with complex needs and high health care costs. This guide harvests the experience of over 200 organizations who...
This resource describes how to develop and implement a model called the Intensive Outpatient Care Program, which uses a multidisciplinary team-based approach to address medical, behavioral, and social...
This resource harvests the lessons learned from eight health care organizations that successfully developed programs for individuals with multiple chronic conditions and functional limitations. Ten...