Resources

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...
How can health care systems across the nation effectively address social needs? An expert committee created by the National Academies of Sciences, Engineering, and Medicine (NASEM) sought to address...
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...
Incorporating patient self-reported data may allow health systems to more effectively identify specific groups of older adults with unique needs, thereby helping to inform the development of patient...
Improving transitions between care settings is critical to achieving positive health outcomes and enhanced quality of life, particularly for dually eligible beneficiaries navigating fragmented...
While Medicare Advantage (MA) plans have new flexibility to target and cover supplemental benefits that address health-related social needs, few plans provided these types of benefits in 2019...
A telephone-based social needs screening, referral, and navigation program that focused on patients with predicted high utilization within the Kaiser Permanente Southern California health system...
Providing supportive housing for individuals experiencing homelessness who are identified as active substance users resulted in lower rates of SUD-related ED visits and hospitalizations compared to...
This blog post highlights how skilled nursing facilities are switching over to the new Patient Driven Payment Model — a payment system that removes therapy minutes as the basis for payment and enhances payment accuracy for therapy, nursing, and ancillary services by making reimbursement dependent on a wide range of clinical characteristics.
This blog post highlights, COACH, a new framework that Camden Coalition utilizes to build authentic relationships with patients and to increase patient engagement.
Developing authentic healing relationships is critical to applying interventions that fully support patients in achieving their goals. The Camden Coalition’s patient engagement framework, COACH, focuses on building these relationships and empowering patients to take full control of their health. This practical play outlines how to use the COACH model and offers tips to providers who wish to enhance patient engagement. DOWNLOAD AS A PDF »
Mapping community resources is a good starting point for developing the system of care needed to interrupt the cycle of hospitalization and emergency department use and create a pathway to health for patients with complex needs. Effective complex care models rest on a foundation of services and supports that go beyond the traditional reach of the health care system. Community asset mapping offers a practical framework for locating and cataloguing a full array of services and for identifying critical care gaps and potential partners. The goal of this play is to help you get started with asset...