Play by Play

Playbook postings and exclusive perspectives from leaders in the field

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In 2016, SMG began an initiative to integrate palliative care services into its primary care practices. However, after encountering challenges, SMG leaders chose to outsource palliative care to an external palliative care agency, Aspire Health. This blog post describes SMG’s experience and offers advice for other ACOs that are struggling to expand palliative care services and looking for a path forward. 
People with complex health and social needs frequently encounter a fragmented healthcare system and experience a lack of continuity of care. In this video series, Caroline Morgan Berchuck, MD describes a promising new complex care hospitalist model that aims to address this fragmentation and support people with complex needs in realizing better health outcomes.
Rachelle Bernacki, MD, MS, talks about the Serious Illness Care Program at Ariadne Labs. Rachelle discusses developing, implementing, and scaling the Serious Illness Care Program as well as a few surprises and challenges she encountered in the development of this program.
What typically happens when a clinician meets a patient with complex care needs? Co-designing care is especially important when the care is for people with complex needs. Here are some tips for co-designing complex care management.
Nearly 12 million individuals are enrolled in both Medicare and Medicaid. This “dually eligible” population has more significant health and functional support needs than either Medicaid-only or Medicare-only populations. At the same time, individuals who are dually eligible face significant challenges in receiving well-coordinated care that is aligned with their needs.
On Thursday, January 17, 2019 , the Playbook presented a webinar exploring how nurses can be integrated into complex care teams. This interactive online discussion provided opportunities to share ideas and ask questions. The panelists had expertise in both nursing and policy. 
Throughout 2018, we have featured several posts authored by the leadership of the Six Foundations Collaborative that supports the Playbook. In honor of the second anniversary of the Playbook’s launch, Jay Want, MD, Executive Director of the Peterson Center on Healthcare, reflects on the philosophy behind the Playbook and shares his vision for its use.

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