Play by Play

Perspectives from leaders in the field of complex care.


This upcoming webinar will feature representatives from three Medicare-Medicaid integrated health plans who will describe their care transition approaches, including how they identify individuals in need of supports, work with delivery system and community-based partners, and address the needs of members with housing insecurity. Speakers will also share program outcomes as well as lessons for health care stakeholders interested in improving care transitions for high-need populations.
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 webinar featured representatives from Adventist Health’s Project Restoration and the Camden Coalition of Healthcare Providers who engaged in a discussion focused on partnerships with multiple sectors, including police, emergency medical services, and community-based health and human services organizations.
This blog post features a conversation with Lauran Hardin, Senior Advisor of Partnerships and Technical Assistance at Camden Coalition, who explores the use of asset mapping to build stronger ecosystems of care, address the root causes of repeated hospital utilization, and improve care delivery for individuals with complex health and social needs.
The challenge of managing Medicare patients with multiple health conditions is familiar to most providers. According to recent data from the Centers for Medicare and Medicaid Services (CMS), two-thirds of Medicare patients have two or more chronic conditions. Establishing treatment guidelines for every condition and for every patient is challenging for a multitude of reasons. A recent study estimated that 37 percent of the average family physician’s time is spent on chronic care, with the balance on acute or preventive care. For Medicare patients, it may be even higher.
For frail older adults with complex care needs, an inpatient hospital stay is destabilizing and often marks the beginning of a decline in functioning. For these older adults and their families, the post-hospital period is a risky, confusing, and stressful time. Providers, payers, hospitals and health systems should look for ways to innovate their care delivery models and to manage and improve care for their patients.