Drawing on a white paper and brief for the Agency for Healthcare Research & Quality, this article summarizes strategies to help smaller primary care practices transform into medical homes that effectively serve patients with complex needs, particularly the frail elderly and working-age adults...

Patients with complex health needs require both medical and social services and support from multiple providers and caregivers, and the patient-centered medical home (PCMH) offers a promising model for providing them comprehensive, coordinated care. Smaller practices, however, face challenges in...

This brief discusses the key components of existing disease management and care management programs that could be incorporated into integrated care programs for Medicare-Medicaid enrollees and other high-cost, high-need Medicaid beneficiaries.

This report for the New York State Health Foundation provides recommendations for New York State as it works to improve the coordination and integration of care dual eligibles receive through Medicare and Medicaid. Key recommendations include using the federal dual eligible demonstration to...

This brief from the Integrated Care Resource Center (ICRC) reviews primary care case management and related FFS models to gather insights into key program design elements needed to manage care for high-need, high-cost beneficiaries with multiple conditions.