Resources

This resource describes a study of five plans that integrate LTSS into care.

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 resource used national survey data from physician practices and ACOs, paired with qualitative interviews, to learn about home visiting programs.

This resource analyzes preventable ED visits and identifies mechanisms for preventing them.

This resource describes an effort to apply a learning health systems approach to reducing ED utilization.

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 is a study evaluating an alternative in-hospital assessment to determine the need for continuing care after discharge.

This resource builds on the seminal Home Alone study, the first national examination at how family caregivers manage medical and nursing tasks. Major findi

This resource describes four care management models that ACOs are using for individuals with complex needs.

This resource, the Partnership Evaluation Tool, is intended to help organizations assess readiness to engage in successful value-based partnerships.

This resource offers a variety of materials about “personas” for different segments of the high-need patient population.