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
All Resources
All Resources
Topics
Populations
Stakeholders
Content Types
Operational Guide to Identify, Understand, and Treat High-Need Patients
Offers a practical framework for safety-net health systems to better identify and segment patients with complex needs, and tailor care models to meet their needs.
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Supporting Family Caregivers Providing Complex Care
Includes promising practices, recommendations, vignettes, and other helpful tools to assist health systems in supporting family caregivers providing complex care.
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Person-Centered Engagement at the Organizational Level
Contains strategies, tips, and case studies to assist health care stakeholders in building meaningful, person-centered engagement in their organizations.
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Medicare-Medicaid Integration: A Reference Guide to Emerging Evidence and Technical Assistance Tools
This reference guide summarizes a set of curated resources to help key stakeholders better understand both the needs of the dually eligible population and emerging evidence and practical approaches for advancing Medicare-Medicaid integration.
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Strategies for Hiring and Training Care Managers in Integrated Programs Serving Medicare-Medicaid Beneficiaries
Describes practical health plan strategies for hiring and training care managers for dual eligible enrollees with complex needs.
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State Pathways to Integrated Care: Exploring Options for Medicare-Medicaid Integration
Outlines steps states can take to advance Medicare-Medicaid integration depending on policy goals, internal capacity, and delivery system structures.
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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.
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Fostering Resilience and Recovery: A Change Package for Advancing Trauma-Informed Primary Care
Implementing a trauma-informed approach in primary care.
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The Guide to Integrating Palliative Care into Population Management
Practical strategies for health plans and ACOs to improve care for patients with serious illness.
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Integrating Community Health Workers on Quality Improvement Teams: Lessons from the Field
Tips on integrating community health workers into quality improvement teams to address patients’ social needs.
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Medications for Addiction Treatment: Providing Best Practice Care in a Primary Care Clinic
Effectively implementing medications for addiction treatment programs in primary care settings.
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A Turning Point in Medicare Policy: Guiding Principles for New Flexibility Under Special Supplemental Benefits for the Chronically Ill
How to implement the new Medicare benefits.
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Taxonomy of Long-Term Services and Supports Integration
A standardized tool to assess where along a continuum a program lies with regard to components of integration.
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The Opioid Use Disorder Prevention Playbook
Strategies for preventing opioid use disorder.
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AAHCM Toolkit: Building Awareness and Engaging Payers to Bring Home-Based Primary Care into the Mainstream
The benefits of home-based primary care.
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June 2019
Identifying and Designing the Right Care Management Program: Insights from ACOs
Four care management models for ACOs.
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Re-envisioning Care for People with Involved Disabilities
Aligning primary care with the “independent living” model for individuals with disabilities.
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