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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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
Aligning Social and Health Care Services: The Case of Community Care Connections
Demonstrates that a program assisting older adults with complex needs in navigating medical and social services may lower acute care utilization.
Peer-Reviewed Article
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
Effective Care Management by Next Generation Accountable Care Organizations
Complex care management program within Next Generation Accountable Care Organizations reduced cost and utilization for high-risk Medicare beneficiaries.
Peer-Reviewed Article
Improving Care for High-Need, High-Cost Patients: The View from a Community Health Worker and a Social Worker
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.
Blog
July 2020
Effects of a Standardized Community Health Worker Intervention on Hospitalization Among Disadvantaged Patients with Multiple Chronic Conditions: A Pooled Analysis of Three Clinical Trials
Using community health workers can reduce hospitalizations in high-risk patients.
Peer-Reviewed Article
Effect of a Comprehensive Cardiovascular Risk Reduction Intervention in Persons With Serious Mental Illness: A Randomized Clinical Trial
A randomized clinical trial of an 18-month comprehensive intervention showed significant reductions in cardiovascular disease risk in adults with serious mental illness.
Peer-Reviewed Article
Evaluation of a National Care Coordination Program to Reduce Utilization Among High-Cost, High-Need Medicaid Beneficiaries with Diabetes
Care coordination program reduces utilization for some high-cost, high-need Medicaid beneficiaries with diabetes.
Peer-Reviewed Article
Integrating Health And Human Services In California’s Whole Person Care Medicaid 1115 Waiver Demonstration
California’s Whole Person Care pilot can inform cross-sector initiatives to improve care for Medicaid enrollees with complex health and social needs.
Peer-Reviewed Article
What’s Next? The Value of Evidence from the Camden Coalition and CareMore Health to Inform Complex Care Program Design
Highlighted lessons from two recent studies to help guide future program and measurement approaches for complex care management interventions.
Webinar
From Camden to Memphis: Recent Complex Care Randomized Controlled Trials Present a Call to Action
Describes key opportunities for the continued development of complex care best practices, gleaned from recent randomized controlled trials.
Blog
March 2020
Impact of Complex Care Management on Spending and Utilization for High-Need, High-Cost Medicaid Patients
Complex care management program for high-need, high-cost Medicaid patients demonstrates substantially lower spending and inpatient utilization.
Peer-Reviewed Article
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
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
The Common Attributes of Successful Care Manager Programs for High-Need, High-Cost Persons: A Cross-Case Analysis
Ten common attributes for successful care management programs serving high-need, high-cost populations.
Peer-Reviewed Article
For the Uninsured in Memphis, a Stronger Safety Net
Moving patients out of the ED and into community support.
Case Example
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
ACO Serious Illness Care: Survey and Case Studies Depict Current Challenges and Future Opportunities
How ACOs are addressing serious illness.
Peer-Reviewed Article