Resources

Care transition interventions can be difficult to successfully implement, but using an evidence-based framework to incorporate stakeholder feedback can help identify barriers to effectiveness...
Complex care management programs implemented by Next Generation Accountable Care Organizations (NGACOs) have shown some success in recent years, but there have been few examples of programs...
Veterans frequently have complex medical, behavioral, and social needs, but often experience barriers in accessing health care services from the Department of Veterans Affairs (VA), the largest...
Understanding where and how high-risk patients receive care can inform efforts to improve care for this population. This study observed care patterns for more than 350,000 high-risk patients within...
While community health worker (CHW) programs that serve low-income populations have demonstrated reductions in preventable acute care utilization, these programs often have limited funding. Developing...
The coronavirus pandemic intensified the already pressing need for the communication and symptom management expertise of palliative care specialists. Amid the surge of COVID-19 cases in New York City...
Health care organizations are increasingly partnering with Area Agencies on Aging (AAAs) to provide social needs support for older adults in the community who are identified with high health risks...
To improve health outcomes and reduce health care costs and utilization for people with complex needs, it is important to understand the underlying social and behavioral issues that may be driving...
Engaging patients in shared decision-making requires providers to integrate patient-identified goals into patient-provider communications. This qualitative study explored how high-need, high-cost...
Adventist Health Clear Lake, a health system in rural California, initiated a cross-sector collaboration between rural service providers and community agencies to more effectively address the needs of...
This resource used national survey data from physician practices and ACOs, paired with qualitative interviews, to learn about home visiting programs. ACO practices were more likely to report using...
This resource describes a national survey of ACOs about initiatives to address serious illness, as well as follow-up case studies. Only 8–21 percent of ACOs have widely implemented serious illness...