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
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
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
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
Embedding Social Workers In Veterans Health Administration Primary Care Teams Reduces Emergency Department Visits
Social workers on rural primary care teams may help decrease high-risk veterans’ acute care use.
Peer-Reviewed Article
Health Care Hotspotting — A Randomized, Controlled Trial
Randomized controlled trial of a care management intervention offers important lessons for the field of complex care.
Peer-Reviewed Article
A Novel Intervention for High-Need, High-Cost Patients: A Study of ECHO Care
Providing virtual case mentoring to outpatient care teams may reduce unnecessary hospital and emergency department visits for high-need, high-cost patients.
Peer-Reviewed Article
ECHO Care: Providing Multidisciplinary Specialty Expertise to Support the Care of Complex Patients
Connecting complex care teams with specialists through videoconferencing can increase their effectiveness in caring for high-need high-cost patients.
Peer-Reviewed Article
AAHCM Toolkit: Building Awareness and Engaging Payers to Bring Home-Based Primary Care into the Mainstream
The benefits of home-based primary care.
Implementation Tool
Impact of Primary Care Intensive Management on High-Risk Veterans’ Costs and Utilization
Supplementing primary care with team-based management.
Peer-Reviewed Article
Outcomes of a Citywide Campaign to Reduce Medicaid Hospital Readmissions with Connection to Primary Care Within 7 Days of Hospital Discharge
The importance of timely primary care follow-up.
Peer-Reviewed Article
Impact of a Complex Chronic Care Patient Case Conference on Quality and Utilization
The case conference approach to caring for complex patients.
Peer-Reviewed Article
Case Management in Primary Care for Frequent Users of Health Care Services: A Mixed Methods Study
The psychological benefits of case management.
Peer-Reviewed Article
Meal Delivery Programs Reduce the Use of Costly Health Care in Dually Eligible Medicare and Medicaid Beneficiaries
Examines how home meal delivery programs show promise for reducing the use of costly health care and decreasing spending for dually eligible individuals.
Peer-Reviewed Article
Community Health Worker Support for Disadvantaged Patients with Multiple Chronic Diseases: A Randomized Clinical Trial
This resource describes the benefits of community health workers for people with multiple chronic conditions.
Peer-Reviewed Article
Disruptive Models in Primary Care: Caring for High-Needs, High-Cost Populations
Promising approaches to managing care illustrated through a clinical vignette.
Case Example
Care Management Plus: Strengthening Primary Care for Patients with Multiple Chronic Conditions
A program to help clinics deliver comprehensive care may decrease mortality and hospitalization rates.
Case Example
New Models of Primary Care Workforce and Financing: Case Example #1: Stanford Coordinated Care
Stanford Coordinated Care provides university employees with complex health needs better care at a lower cost
Case Example
Guided Care: A Structured Approach to Providing Comprehensive Primary Care for Complex Patients
Guided Care is designed to strike a balance between telephone-based and interdisciplinary team-based care management programs.
Case Example