Resources

To improve the quality and value of care and target interventions most effectively, it is important to understand the distinction between individuals with complex health and social needs who have...
Despite mounting evidence for community health workers (CHWs) and peer providers improving health outcomes, the expansion of the community-based workforce in the health care system has been limited...
The coronavirus pandemic intensified the already pressing need for the communication and symptom management expertise of palliative care specialists. Amid the surge of COVID-19 cases in New York City...
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...
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 provides guidelines for implementing Special Supplemental Benefits for the Chronically Ill (SSBCI) in a manner that improves health care for chronically ill Medicare beneficiaries. The...
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 used national survey data from physician practices and ACOs, paired with qualitative interviews, to learn about home visiting programs. ACO practices were more likely to report using...
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 an effort to apply a learning health systems approach to reducing ED utilization. A learning health system focuses on improving people’s health at scale through continuous...
This resource describes four care management models that ACOs are using for individuals with complex needs. Care management programs can involve creating patient care plans, coordinating care across...