Resources

While health care quality improvement teams often involve clinical staff, these teams would benefit from the inclusion of community health workers (CHWs), who can provide insights into patient needs...
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 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...
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 older adults. HBPC providers...
This resource is a toolkit highlighting innovative care coordination strategies used by Medicare ACOs. ACOs use a variety of methods to coordinate and manage the care of their populations, including...
This resource is a toolkit for identifying patients with various physical, functional, emotional, social, and spiritual needs. Patients and families living with serious illness have a range of needs...
This resource describes four care management models that ACOs are using for individuals with complex needs. Care management programs can involve creating patient care plans, coordinating care across...
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” model. The first video...
This resource, the Partnership Evaluation Tool, is intended to help organizations assess readiness to engage in successful value-based partnerships. It can be used to assess potential partners or for...
This resource offers a variety of materials about “personas” for different segments of the high-need patient population. A persona helps depict the experiences, motivations, and goals of a group of...
This tool is a calculator designed to assist community-based organizations and their health care partners in creating financial arrangements to fund social services for patients with complex needs. It...
This resource provides guidance for state leaders in establishing and advancing complex care programs. Since 2013, the National Governors Association Center for Best Practices (NGA Center) Health...