A community health worker and social worker from CareMore Health share their perspective on the importance of their roles in lowering costs and improving outcomes for high-need patients.

Describes key opportunities for the continued development of complex care best practices, gleaned from recent randomized controlled trials.

Highlights how skilled nursing facilities are switching to the Patient Driven Payment Model — a payment system that removes therapy minutes as the basis for payment and enhances payment accuracy for services by making reimbursement dependent on a wide range of clinical characteristics.

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.