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
Accountable Care Organization Care Transformation Toolkit
Provides practical steps for current or potential future Medicare accountable care organizations to transform the delivery of care.
Implementation Tool
Lessons Learned from the Transition from Volume to Value
Describes factors that support health care organizations in transitioning from volume- to value-based payment.
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
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
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
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
Beyond the Camden Coalition’s Randomized Controlled Trial: Lessons for the Complex Care Field on Addressing Patient Needs
Features David Labby, MD, health strategy advisor for Health Share of Oregon, who provides insights on the recently released report on Camden Coalition's randomized controlled trial on the Camden Core Model.
Blog
February 2020
Health Care Spending and Use Among People Experiencing Unstable Housing in the Era of Accountable Care Organizations
Individuals experiencing homelessness had health care spending 2.5 times higher than the comparison Medicaid population.
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
Fostering Resilience and Recovery: A Change Package for Advancing Trauma-Informed Primary Care
Implementing a trauma-informed approach in primary care.
Implementation Tool
Building Blocks of Primary Care, Part 2: Better Between-Visit Care with Chronic Care Management
Our ability to effectively treat the growing number of individuals who live with multiple chronic diseases will remain compromised unless health systems explore innovative approaches.
Blog
October 2019
Building Blocks of Robust Primary Care Delivery, Part 1: Moving from Reactive to Proactive Care with the Annual Wellness Visit
The time constraints of the typical primary care practice often do not allow providers to take a comprehensive look at all of their patients’ needs. Enabling office staff to assist in this work, presents a tremendous opportunity to create patient-centered and comprehensive care plans.
Blog
August 2019
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