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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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
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
COVID-19 Social Health Playbook
Presents tools and tips frontline care management staff to address high-risk patients’ unmet social health needs during the COVID-19 pandemic.
Implementation Tool
Integrated Care Programs for Dually Eligible Individuals in the Era of COVID-19: Response Efforts and Policy Recommendations
Identifies opportunities to strengthen integrated programs to improve care and support positive health outcomes for dually eligible individuals both during and beyond the pandemic.
Brief/Report
Making Lemonade from a Very Sour Lemon: Capitalizing on Regulatory Flexibilities Born from the COVID-19 Public Health Emergency
Highlights opportunities for long-term care providers to leverage federal and state flexibilities to adopt new ways of delivering services to older adults and people with complex needs, as well as addressing barriers to care created by the COVID-19 pandemic.
Blog
August 2020
How Community Health Workers and Promotores Can Support Individuals with Complex Needs amid COVID-19
Explored opportunities for health systems and plans to work with CHW/Ps to support high-need individuals, with a focus on addressing the long-term impacts of the COVID-19 pandemic.
Webinar
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
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
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
Empowering Goals of Care for Vulnerable Communities During COVID-19
Details the proactive approach of Cambridge Health Alliance, a public ambulatory care and hospital system in the Boston area, to initiate goals of care conversations with high-risk patients in their respiratory clinic.
Blog
June 2020
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
Medicare Advantage Plans have a Unique Opportunity to Provide Needed Non-Medical, Health-Related Services During COVID-19
Explores opportunities for Medicare Advantage plans to provide non-medical supplemental benefits during COVID-19 — including in-home supports, meal and grocery deliveries, home modifications, and transitional supports — to help Medicare beneficiaries shelter at home.
Blog
May 2020
A Beacon for Dark Times: Palliative Care Support During the Coronavirus Pandemic
Hospital system call line expands access to palliative care supports amid COVID-19.
Peer-Reviewed Article
Integrating Care for Dually Eligible Individuals Matters Even More in the Face of COVID-19
Melanie Bella, former director of the Medicare-Medicaid Coordination Office at the Centers for Medicare & Medicaid Services, explores implications of COVID-19 to influence the future landscape for integrating Medicare and Medicaid services.
Blog
May 2020
Deploying Virtual Care During COVID-19 and Beyond
When the COVID-19 pandemic struck, One Community Health partnered with OCHIN to rapidly transform its care delivery model, implementing new virtual care tools to safely and effectively serve vulnerable patients with complex needs through the pandemic and beyond.
Blog
May 2020
Identifying Patients with Increased Risk of Severe Covid-19 Complications: Building an Actionable Rules-Based Model for Care Teams
Provider-based model identifies patients at highest risk for complications from COVID-19.
Peer-Reviewed Article
Addressing Complex Care Needs Amid COVID-19
Curates federal guidance aimed at addressing COVID-19 for people with complex care needs, as well as targeted resources to help guide complex care programs in adopting new strategies to address COVID-19.
Website/Resource Center