Care Coordination

Prior research from the U.S. Department of Health and Human Services (HHS) Office of the Assistant Secretary for Planning and Evaluation (ASPE) and U.S. Department of Housing and Urban Development (HUD) Office of Policy Development and Research (PD&R) show older adults receiving federal housing assistance face disproportionately high rates of chronic conditions and health care utilization.

ASPE serves as a facilitator for HHS to advance equity in several ways.

This is the final report of an AHRQ study to address the operational gap between CFIs and EFIs. This project focused on validating an established CFI using linked claims-EHR databases of multiple large health systems. The project provides a systematic approach that health systems can use to examine the quality of the EHR data and prepare it for the application of EFI measures.

This brief is the third publication from the Continuity of Care Services Following Coordinated Specialty Care study. It provides a short overview of the different approaches to continuity of care for young adults who have attended CSC programs and explores avenues for integration within programs and organizations as a way to support young adults following a completion of a CSC program.

The Coordinated Specialty Care Transition Study: Final Report provides an overview of transition services for clients graduating from Coordinated Specialty Care (CSC). This the second publication from the Continuity of Care Services Following Coordinated Specialty Care study.

Dual eligible beneficiaries are an important subset of the Medicare and Medicaid populations because they have a high prevalence of chronic conditions and disabilities, substantial care needs, and high health care and long-term services and supports (LTSS) utilization and costs.

This report summarizes the research literature on care coordination for people with Alzheimer’s disease, with a particular focus on programs that coordinate both medical care and long-term services and supports. Overall, there is limited evidence of the effectiveness of these programs in improving patient outcomes or reducing health care utilization.

Literature Review

This report describes a range of approaches state Medicaid agencies use to coordinate health services and to coordinate long-term care services with health services for beneficiaries with chronic conditions. It then describes in detail two innovative programs: Georgia's SOURCE program and the Indiana Chronic Disease Management Program. [66 PDF pages]