Resources

This analysis compared Medicare Advantage (MA) enrollees’ demographic, socioeconomic, and clinical characteristics plus health care utilization, spending, and quality of care in 2012 and 2015, and...
A majority of mature accountable care organizations (ACOs) segment their high-need, high-cost (HNHC) population into smaller subgroups to better identify those with similar needs, employing a range of...
Approximately one in three Medicare beneficiaries is enrolled in a Medicare Advantage (MA) plan, and more than one third of these MA enrollees are classified as high need based on their chronic...
This resource describes a new model that moves high-need patients out of the emergency department and into a network of social supports. Regional One Health, a large health system in Tennessee, has...
Based on a review of the evidence, the Quick Reference Guide to Promising Care Models offers summary information on 28 programs for adults with complex needs, specifically: Target population and...
This resource describes a promising new hospitalist model for inpatient treatment of complex care patients. In July 2016, Commonwealth Care Alliance and Boston Medical Center created a hospitalist...
Throughout the country, efforts are increasingly emerging to integrate social services into health care systems. This resource classifies new initiatives, identifies common challenges, and proposes...
This resource shares 10 questions that California’s Medicaid managed care plans are now required to ask patients about their social and functional needs. These questions could serve as a model for...
This resource provides a summary of key components of the Creating High-Quality Results and Outcomes Necessary to Improve Chronic (CHRONIC) Care Act, which was passed and signed on February 9, 2018...
The Massachusetts Health Policy Commission's Community Hospital Acceleration, Revitalization, and Transformation (CHART) investment program has engaged 25 community hospitals to advance readiness for...
​​​​ This resource describes a program in New Mexico that employs community health workers (CHWs) to address social determinants of health, as well as how that program was implemented and spread. CHWs...
This resource proposes a framework to help guide the development of programs for populations with complex needs. While medical drugs and devices go through a well-established, rigorous development...