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.
Brief/Report
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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
Ten Lessons from the C-Suite: Health Care Leaders Shed Light on Margin, Mission, and the Five Percent
Shares current health care leaders’ perspectives on the emerging field of complex care and how they are working to solve its so-called "margin-mission" tension.
Blog
October 2020
Reimbursement for Evidence-Based Health Promotion Programs in the Community
Details funding opportunities and successful approaches in the adoption of evidence-based health promotion and disease prevention programs within community-based organizations.
Brief/Report
How a Nonprofit Organization Gets Paid to Address Health-Related Social Needs
Highlights how the Commonwealth Fund's social determinants of health ROI calculator can help community-based organizations and health system partners integrate nonmedical services in a financially sustainable way.
Blog
July 2020
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
Where is the Break-even Point for Community Health Workers? Using National Data and Local Programmatic Costs to Find the Break-even Point for a Metropolitan Community Health Worker Program
Community health worker programs can offset program costs through reduced utilization.
Peer-Reviewed Article
Health Care Access Now: Calculating the ROI of a Care Coordination Program to Address Social Determinants of Health
Demonstrating return-on-investment to advance effective business relationships between community-based organizations and health care partners.
Case Example
Homage: Calculating the ROI of a Partnership to Meet the Health-Related Social Needs of Medicare Advantage Plan Members
How can a community-based organization demonstrate the two-way financial benefits of partnering with a health plan?
Case Example
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
Evidence-Based Community Health Worker Program Addresses Unmet Social Needs And Generates Positive Return On Investment
A community health worker program yielded an annual return of $2.47 for every dollar invested by a Medicaid payer.
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