This resource offers a structured improvement process for redesigning care for people with complex needs and high health care costs.

This resource describes how to develop and implement a model called the Intensive Outpatient Care Program, which uses a multidisciplinary team-based approach to address medical, behavioral, and soc

Based on a review of the evidence, the Quick Reference Guide to Promising Care Models offers summary information on 22 programs for adults with complex needs.

This resource provides personas, which are character profiles aggregated from a collection of interviews with members of a population, for three subgroups of the high-need population.


This resource reviews the case for segmenting patients with complex needs and different ways of segmenting, as well as challenges and limitations.

This paper provides promising policy recommendations to improve care for high-need, high-cost patients.

This report explores key issues, spending implications, and existing barriers to meeting the needs of high-need, high-cost patients.

This resource examines reimbursement structures that serve beneficiaries who are dually eligible for Medicare and Medicaid.

As the health care system shifts from a fee-for-service structure to value-based payment programs, it’s important to offer appropriate services across the continuum of care.

This resource provides a structured approach to evaluating non-medical areas of risk, such as ability for self-management (e.g., cognition, understanding, confidence, etc.), social support or isola

This resource explores how measuring patients’ activation levels can help identify those individuals at higher risk for poor health outcomes and utilization of avoidable costly care.

This resource reviews strategies to identify patients who are likely to require high-cost care.