Medical Care at Home Comes of Age
Provides an overview of home-based medical care models, the patients that they serve, and their robust evidence base.
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“Eyes in the Home”: Addressing Social Complexity in Veterans Affairs Home-Based Primary Care
Home-based primary care programs enable care teams to gain insights on a variety of social factors that impact older adults’ health, which allows them to better tailor care to meet patient needs.
Peer-Reviewed Article
The PACE Response to COVID-19 Calls for Policy Actions Increasing Access and Affordability
Highlights PACE programs’ efforts to redesign care during the COVID-19 pandemic and presents policy options that may help to expand access to the programs in the future.
Blog
October 2020
A Systematic Review of Intensive Outpatient Care Programs for High-Need, High-Cost Patients
Demonstrates that intensive outpatient care programs show promise in reducing utilization and costs and improving patient outcomes for high-need, high-cost populations.
Peer-Reviewed Article
COVID-19 Social Health Playbook
Presents tools and tips frontline care management staff to address high-risk patients’ unmet social health needs during the COVID-19 pandemic.
Implementation Tool
Integrated Care Programs for Dually Eligible Individuals in the Era of COVID-19: Response Efforts and Policy Recommendations
Identifies opportunities to strengthen integrated programs to improve care and support positive health outcomes for dually eligible individuals both during and beyond the pandemic.
Brief/Report
Making Lemonade from a Very Sour Lemon: Capitalizing on Regulatory Flexibilities Born from the COVID-19 Public Health Emergency
Highlights opportunities for long-term care providers to leverage federal and state flexibilities to adopt new ways of delivering services to older adults and people with complex needs, as well as addressing barriers to care created by the COVID-19 pandemic.
Blog
August 2020
How Community Health Workers and Promotores Can Support Individuals with Complex Needs amid COVID-19
Explored opportunities for health systems and plans to work with CHW/Ps to support high-need individuals, with a focus on addressing the long-term impacts of the COVID-19 pandemic.
Webinar
Age-Friendly Health Systems: Guide to Using the 4Ms in the Care of Older Adults
Step-by-step guide with robust tools for health systems to apply the 4Ms framework to deliver age-friendly, evidence-based care for older adults.
Implementation Tool
Caring for Older Adults with Complex Needs in the COVID-19 Pandemic: Lessons from PACE Innovations
Highlighted innovations adopted by PACE organizations during the pandemic to provide care for older adults with complex needs.
Webinar
Use of General Primary Care, Specialized Primary Care, and Other Veterans Affairs Services Among High-Risk Veterans
Integrated health care systems can better support high-risk patients by embedding high-risk patient care within general primary care and mental health care.
Peer-Reviewed Article
Empowering Goals of Care for Vulnerable Communities During COVID-19
Details the proactive approach of Cambridge Health Alliance, a public ambulatory care and hospital system in the Boston area, to initiate goals of care conversations with high-risk patients in their respiratory clinic.
Blog
June 2020
The Effects of an Enhanced Primary Care Model for Patients with Serious Mental Illness on Emergency Department Utilization
Enhanced primary care for Medicaid enrollees with serious mental illness can help decrease emergency department use over time.
Peer-Reviewed Article
Medicare Advantage Plans have a Unique Opportunity to Provide Needed Non-Medical, Health-Related Services During COVID-19
Explores opportunities for Medicare Advantage plans to provide non-medical supplemental benefits during COVID-19 — including in-home supports, meal and grocery deliveries, home modifications, and transitional supports — to help Medicare beneficiaries shelter at home.
Blog
May 2020
A Beacon for Dark Times: Palliative Care Support During the Coronavirus Pandemic
Hospital system call line expands access to palliative care supports amid COVID-19.
Peer-Reviewed Article
Integrating Care for Dually Eligible Individuals Matters Even More in the Face of COVID-19
Melanie Bella, former director of the Medicare-Medicaid Coordination Office at the Centers for Medicare & Medicaid Services, explores implications of COVID-19 to influence the future landscape for integrating Medicare and Medicaid services.
Blog
May 2020
Deploying Virtual Care During COVID-19 and Beyond
When the COVID-19 pandemic struck, One Community Health partnered with OCHIN to rapidly transform its care delivery model, implementing new virtual care tools to safely and effectively serve vulnerable patients with complex needs through the pandemic and beyond.
Blog
May 2020
Identifying Patients with Increased Risk of Severe Covid-19 Complications: Building an Actionable Rules-Based Model for Care Teams
Provider-based model identifies patients at highest risk for complications from COVID-19.
Peer-Reviewed Article
Addressing Complex Care Needs Amid COVID-19
Curates federal guidance aimed at addressing COVID-19 for people with complex care needs, as well as targeted resources to help guide complex care programs in adopting new strategies to address COVID-19.
Website/Resource Center
All Hands on Deck: How Commonwealth Care Alliance is Rethinking Protocol to Address COVID-19
Features a conversation with Lori Tishler, senior vice president of medical services at Commonwealth Care Alliance, who shares how CCA is rethinking its day-to-day practice to address the COVID-19 pandemic.
Blog
April 2020