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...
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 describes a study of five plans that integrate LTSS into care. The study examined differences in medical utilization by beneficiaries, compared to a population with a similar level of...
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...