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Evidence is mounting about the importance of robust primary care in achieving the Triple Aim of advancing quality of care, reducing costs, and improving the patient experience. Primary care initiatives across the country have shown that enhancing primary care can coordinate service delivery to the benefit of both patients and clinicians. In Medicare accountable care organizations (ACOs), primary care transformation has been foundational for shifting to a team-based approach that reaps benefits for patients, providers, and payers.
The individual characteristic that contributes most to complex care needs is the inability to function in activities of daily living (ADLs), such as eating, bathing, and dressing. The winners in population health management will be the health plans and providers that figure out how to identify individuals with ADL impairment and address their needs with comprehensive care management and targeted non-medical services.

Senior living refers to a range of service-enriched housing aimed at older adults who want specific service amenities, health care support, or help with activities of daily living (e.g., dressing). Many forms of senior living, such as assisted living, evolved to offer an alternative to nursing homes — to provide a safe version of home that prioritizes hospitality, comfort, and independence over the constant supervision and medical care of a 24-hour facility. Examples of senior living include independent and assisted living.

Person-centered care is of critical importance to the care of people with involved disabilities. This blog describes a series of video modules for health system leaders and clinicians that aims to reinvigorate the idea of person-centered care for those with complex health, social, and functional needs
In 2016, SMG began an initiative to integrate palliative care services into its primary care practices. However, after encountering challenges, SMG leaders chose to outsource palliative care to an external palliative care agency, Aspire Health. This blog post describes SMG’s experience and offers advice for other ACOs that are struggling to expand palliative care services and looking for a path forward. 
People with complex health and social needs frequently encounter a fragmented healthcare system and experience a lack of continuity of care. In this video series, Caroline Morgan Berchuck, MD describes a promising new complex care hospitalist model that aims to address this fragmentation and support people with complex needs in realizing better health outcomes.
Rachelle Bernacki, MD, MS, talks about the Serious Illness Care Program at Ariadne Labs. Rachelle discusses developing, implementing, and scaling the Serious Illness Care Program as well as a few surprises and challenges she encountered in the development of this program.

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