Resources

While community health worker (CHW) programs that serve low-income populations have demonstrated reductions in preventable acute care utilization, these programs often have limited funding. Developing...
Health care organizations are increasingly partnering with Area Agencies on Aging (AAAs) to provide social needs support for older adults in the community who are identified with high health risks...
To improve health outcomes and reduce health care costs and utilization for people with complex needs, it is important to understand the underlying social and behavioral issues that may be driving...
Adventist Health Clear Lake, a health system in rural California, initiated a cross-sector collaboration between rural service providers and community agencies to more effectively address the needs of...
A majority of mature accountable care organizations (ACOs) segment their high-need, high-cost (HNHC) population into smaller subgroups to better identify those with similar needs, employing a range of...
While Medicare Advantage (MA) plans have new flexibility to target and cover supplemental benefits that address health-related social needs, few plans provided these types of benefits in 2019...
This resource describes a study of five plans that integrate LTSS into care. The study examined differences in medical utilization by beneficiaries, compared to a population with a similar level of...
This resource provides a framework for understanding the nature and extent of integration in programs that integrate LTSS with medical care and behavioral health. This taxonomy is a standardized tool...
This resource describes a national survey of ACOs about initiatives to address serious illness, as well as follow-up case studies. Only 8–21 percent of ACOs have widely implemented serious illness...
This resource describes the strategies employed by ACOs that have comprehensive care management programs for complex patients. This report is from the six-foundation collaborative and is based on...
This resource examines three innovative models for treating patients with serious illness, developed by third-party firms that contract with Medicare Advantage plans. The financing structure of...
This resource provides a summary of key components of the Creating High-Quality Results and Outcomes Necessary to Improve Chronic (CHRONIC) Care Act, which was passed and signed on February 9, 2018...