Resources

Although health care systems commonly refer individuals with unmet social needs to social service agencies, in some cases, these agencies may not have the capacity to provide adequate assistance. This...
Integrated primary care teams have demonstrated positive impacts on patient care, but less is known about the impact of including social workers on these teams. This study evaluated the addition of...
In this blog post, Melanie Bella, MBA, chief of new business and policy at Cityblock Health and former director of the Medicare-Medicaid Coordination Office at the Centers for Medicare & Medicaid Services, explores implications of the current moment to influence the future landscape for integrating Medicare and Medicaid services.
Whole Person Care (WPC) pilots, under California’s Medicaid Section 1115(a) waiver demonstration, integrate medical, behavioral health, and social needs services to improve the health and wellbeing of...
Health care organizations are increasingly partnering with Area Agencies on Aging (AAAs) to provide social needs support for older adults in the community who are identified with high health risks...
Effective patient-centered case management interventions can potentially improve health and social outcomes for individuals experiencing homelessness or housing instability. This literature review...
One Community Health has been providing innovative health care in a rural region of the Pacific Northwest for more than 30 years. When the COVID-19 pandemic struck, the health center partnered with OCHIN to rapidly transform its care delivery model, implementing new virtual care tools to safely and effectively serve vulnerable patients with complex needs through the pandemic and beyond.
To improve health outcomes and reduce health care costs and utilization for people with complex needs, it is important to understand the underlying social and behavioral issues that may be driving...
Engaging patients in shared decision-making requires providers to integrate patient-identified goals into patient-provider communications. This qualitative study explored how high-need, high-cost...
This blog post features a conversation with Terry Fulmer, president of the John A. Hartford Foundation, who explores the NASEM report findings and discuss potential solutions for older adults experiencing social isolation and loneliness — both during and after the COVID-19 pandemic.
Many older adults experience loneliness, which can lead to harmful impacts on mental as well as physical health. This literature review evaluated the effectiveness of published studies of...
While high-cost patients include diverse subgroups with varying clinical and social needs, efforts to improve the efficiency of care and target interventions have been limited by the lack of knowledge...