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...
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...
While health care quality improvement teams often involve clinical staff, these teams would benefit from the inclusion of community health workers (CHWs), who can provide insights into patient needs...
The Return-on-Investment (ROI) Calculator for Partnerships to Address the Social Determinants of Health, developed by The Commonwealth Fund, is designed to support successful financial partnerships...
Complex care programs across the country use varied criteria to identify people with complex health and social needs and measure the effectiveness of subsequent interventions. Greater standardization...
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...
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...
High-need, high-cost Medicaid patients enrolled in a 12-month complex care management program at CareMore Health in Memphis, Tennessee experienced reductions of 59 percent in inpatient utilization and...
Project ECHO (Extension for Community Health Outcomes) virtually connects specialists with community-based providers to help improve patient care management. This evaluation of the ECHO Care pilot...
The number of individuals living with dementia is steadily increasing, and family caregivers for individuals with dementia frequently experience challenges with maintaining their own physical...
A randomized controlled trial found that the “Camden Core Model,” a short-term care management program for individuals with complex health and social needs and multiple recent hospital admissions, did...
How can health care systems across the nation effectively address social needs? An expert committee created by the National Academies of Sciences, Engineering, and Medicine (NASEM) sought to address...