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
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
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
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 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
‘Eyes in The Home’: ACOs Use Home Visits to Improve Care Management, Identify Needs, And Reduce Hospital Use
How home visits are used by ACOs to improve care, lower costs.
Peer-Reviewed Article
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
Identifying and Designing the Right Care Management Program: Insights from ACOs
Four care management models for ACOs.
Implementation Tool
The Complex Care Hospitalist Program at Boston Medical Center
Caroline Morgan Berchuck, MD, describes a promising new complex care hospitalist model that aims to address this fragmentation and support people with complex needs in realizing better health outcomes.
Blog
March 2019