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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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
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
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 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
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
Care Management for Older Adults: The Roles of Nurses, Social Workers, and Physicians
How staff composition affects care delivery for older adults.
Peer-Reviewed Article
Time and Effort in Care Coordination for Patients with Complex Health and Social Needs: Lessons From a Community-Based Intervention
Staff time effort in complex care coordination programs is highly variable depending on patients’ health and social needs.
Peer-Reviewed Article
How ACOs Are Caring for People with Complex Needs
An analysis of the National Survey of ACOs
Brief/Report
Outpatient Complex Case Management: Health System-Tailored Risk Stratification Taxonomy to Identify High-Cost, High-Need Patients
Maximizing the impact of outpatient complex case management.
Peer-Reviewed Article
Going Beyond Clinical Care to Reduce Health Care Spending
A regional approach to health care transformation.
Peer-Reviewed Article
Active Redesign of a Medicaid Care Management Strategy for Greater Return on Investment: Predicting Impactability
This resource describes one tool to identify patients most likely to benefit from care management.
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
Integrating Health Care for High-Need Medicaid Beneficiaries With Serious Mental Illness and Chronic Physical Health Conditions at Managed Care, Provider, and Consumer Levels
This resource describes the value of navigators for Medicaid beneficiaries with mental illness.
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