People with Advanced Illness Resources

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 o

A telephone-based social needs screening, referral, and navigation program that focused on patients with predicted high utilization within the Kaiser Permanente Southern Cal

This resource describes a quasi-experimental study evaluating the effect of a transitional care program that involved rapid primary care follow-up

This resource describes a new model that moves high-need patients out of the emergency department and into a network of social supports.

Family caregivers play a foundational role in the care of older adults with complex needs and disabilities from both a health care and economic standpoint.

Family caregivers are a critical part of the home- and community-based workforce for people with serious illness.

This resource provides guidelines for implementing Special Supplemental Benefits for the Chronically Ill (SSBCI) in a manner that improves health care for chron

This resource provides a framework for understanding the nature and extent of integration in programs that integrate LTSS with medical care and behavioral health.

This resource used national survey data from physician practices and ACOs, paired with qualitative interviews, to learn about home visiting programs.

This resource describes and evaluates a new specialist pharmacy service, called the integrated care clinical pharmacist.

This resource analyzes preventable ED visits and identifies mechanisms for preventing them.

This resource describes a national survey of ACOs about initiatives to address serious illness, as well as follow-up case studies.