Resources

This resource describes a new model that moves high-need patients out of the emergency department and into a network of social supports.

Family caregivers play a foundational role in the care of older adults with complex needs and disabilities from both a health care and economic standpoint.

Family caregivers are a critical part of the home- and community-based workforce for people with serious illness.

This resource is a toolkit to help payers and providers understand how home-based primary care (HBPC) improves quality and reduces costs for seriously ill and home-limited o

This resource describes a randomized controlled trial to evaluate the effects of a case management intervention called V1SAGES (Vulnerable Patients in Primary Care: Nurse Ca

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 is a series of four videos (each roughly 12 minutes long) about how to transform care for people with involved disabilities according to the “independent living” mod

This resource describes the 7-Day Pledge program to reduce readmissions by increasing access to timely primary care appointments after hospitalization.

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