Resources

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 an effort to apply a learning health systems approach to reducing ED utilization. A learning health system focuses on improving people’s health at scale through continuous...
This resource describes a study of the Johns Hopkins Community Health Partnership (J-CHiP), which was created as a regional approach to health care transformation in Baltimore, Maryland. J-CHiP...
This resource describes a randomized quality improvement trial that assessed whether augmenting usual primary care with team-based intensive management lowers utilization and costs for high-risk...
This resource describes the evolution of complex care management targeting strategies in Community Care of North Carolina’s (CCNC) work with the statewide non-dual Medicaid population, culminating in...
This resource provides a roadmap for health plans providing complex chronic care to improve quality and their Medical Loss Ratio (MLR), a basic financial measurement used in the Affordable Care Act to...
This resource describes the Complex Care Map (CCM ©), a tool that addresses fragmentation in the health system and helps providers understand the patient’s story. It was implemented in a quality...
This resource describes a care guidance index based on what matters to patients. Identifying a high-risk subgroup is a strategy for chronic care management. However, common methods of assessing risk...
This study examined five programs that serve patients with complex needs through medical and non-medical services. Authors created a framework to illustrate the foundational factors that encourage...
This viewpoint article argues that policy can play an important role in improving outcomes for people with complex needs in the US, and it makes several recommendations for the current federal...
The problem of the high cost of health care has centered on reducing spending among the patients who use the most health care services. This article explains why reducing waste system-wide for all...