Resources

Care transition interventions can be difficult to successfully implement, but using an evidence-based framework to incorporate stakeholder feedback can help identify barriers to effectiveness...
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...
IMPaCT is a standardized community health worker (CHW) intervention for high-risk patients that has been previously evaluated in three randomized clinical trials across various clinical settings and...
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...
Accountable care organizations (ACOs) have shown promise in improving care for individuals with chronic conditions who also have coexisting mental health conditions, in part by incentivizing hospitals...
Medicaid health homes were created by the Affordable Care Act to improve care for Medicaid enrollees with complex behavioral and physical health needs. Health homes that target behavioral health...
Although health care systems commonly refer individuals with unmet social needs to social service agencies, in some cases, these agencies may not have the capacity to provide adequate assistance. This...
Integrated primary care teams have demonstrated positive impacts on patient care, but less is known about the impact of including social workers on these teams. This study evaluated the addition of...
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...
Engaging patients in shared decision-making requires providers to integrate patient-identified goals into patient-provider communications. This qualitative study explored how high-need, high-cost...