Objective To conduct a scoping review of models of care for chronic disease management to
identify potentially effective components for management of chronic traumatic brain injury …

Importance Medically complex patients are a heterogeneous group that contribute to a
substantial proportion of health care costs. Coordinated efforts to improve care and reduce …

Background Chronic disease patients who are the greatest users of healthcare services are
often referred to as high-need, high-cost (HNHC). Payers, providers, and policymakers in the …

Objective To analyze the effects of a standardized community health worker (CHW)
intervention on hospitalization. Data Sources/Study Setting Pooled data from three …

Objective We aimed to explore the construct of “high need” and identify common need
domains among high-need patients, their care professionals, and healthcare organizations; …

While an emerging body of evidence suggests that medical homes may yield more benefits
than traditional care models do, the role of social workers within medical homes has yet to …

Background Care coordination (CC) interventions involve systematic strategies to address
fragmentation and enhance continuity of care. However, it remains unclear whether CC can …

Objective To identify opportunities to align care with the personal values of patients from
three distinct groups with complex medical, behavioral, and social needs. Data …

Importance Integrated health care systems increasingly focus on improving outcomes
among patients at high risk for hospitalization. Examining patterns of where patients obtain …

Objective Many healthcare systems employ population-based risk scores to prospectively
identify patients at high risk of poor outcomes, but it is unclear whether single point-in-time …