Chronic and Complex Populations
FEATURED ARTICLE
Shaking Up the Delivery of Traditional Mental Health Services
/in Policy Blogs Behavioral/Mental Health and SUD, Care Coordination, Chronic and Complex Populations, Cost, Payment, and Delivery Reform, Health System Costs, Physical and Behavioral Health Integration, Primary Care/Patient-Centered/Health Home, Workforce Capacity /by Mary TakachSeveral primary health care organizations (PHCOs) that I have spoken with in the states and in Australia during my 10-month fellowship have established a central referral point or “one stop shop” to help primary care practices connect their patients to community-based mental health and/or substance abuse services. These referral centers can take the load off […]
Cross-Systems Collaboration: Working Together to Identify and Support Children and Youth with Special Health Care Needs
/in Policy Webinars Children/Youth with Special Health Care Needs, CHIP, Chronic and Complex Populations, Eligibility and Enrollment, EPSDT, Essential Health Benefits, Health Coverage and Access, Healthy Child Development, Integrated Care for Children, Maternal, Child, and Adolescent Health, Safety Net Providers and Rural Health /by NASHPTuesday, March 3, 2015: Multiple state agencies and organizations are working to identify and support children with special physical, emotional and developmental disabilities. Coordination and collaboration across systems, including the sharing of data, increases the ability for states to identify children at risk and ensure they are receiving the appropriate health, mental health and developmental services. This webinar features three states discussing collaborations across state programs that impact the identification and treatment of children in need of specific services.
Population Health Components of State Innovation Model (SIM) Plans: Round 2 Model Testing States
/in Policy Accountable Health, Behavioral/Mental Health and SUD, Care Coordination, Chronic and Complex Populations, Chronic Disease Prevention and Management, Community Health Workers, Cost, Payment, and Delivery Reform, Health Equity, Health System Costs, Physical and Behavioral Health Integration, Population Health, Primary Care/Patient-Centered/Health Home, Quality and Measurement, Social Determinants of Health /by NASHP*Chart updated March 6, 2015 The Round Two State Innovation Model (SIM) Test Awards granted by HHS to eleven states (Colorado, Connecticut, Delaware, Idaho, Iowa, Michigan, New York, Rhode Island, Ohio, Tennessee, and Washington) support state efforts to build multi-payer models of health system transformation. As noted in a previous analysis, population health improvement is […]
Pilots in Colorado and Western Australia Integrate Paramedics into Care Team
/in Policy Colorado Blogs Care Coordination, Chronic and Complex Populations, Cost, Payment, and Delivery Reform, Health System Costs /by NASHP and Mary TakachWalkabout Medical Homes with Mary Takach: A 10-month Study of Australia February 2015 Reducing inappropriate utilization of the emergency department (ED) is a very common focus of health systems, payers, and practices seeking to improve health care quality and reduce costs. To help break the cycle of non-emergency ED use lists of “superutilizers” are generated […]
Integrating Community Health Worker Models into Evolving State Health Care Systems
/in Policy Chronic and Complex Populations, Chronic Disease Prevention and Management, Community Health Workers, Cost, Payment, and Delivery Reform, Health System Costs, Long-Term Care, Medicaid Managed Care, Palliative Care, Population Health /by NASHPMonday, February 23, 2015 Moderator: CDR Thomas Pryor United States Public Health Service, Center for Medicare & Medicaid Innovation Project Officer Presenters: Gail Hirsch Director, Office of Community Health Workers, Massachusetts Department of Public Health Kari Armijo Health Care Reform Manager, Medical Assistance Division, New Mexico Human Services Department Allie Gayheart Manager of Health Initiatives, […]
The State of State Health Policy: Governors’ 2015 State of the State Addresses
/in Policy Reports Behavioral/Mental Health and SUD, Chronic and Complex Populations, Community Health Workers, Cost, Payment, and Delivery Reform, Health System Costs, Healthy Child Development, Long-Term Care, Maternal, Child, and Adolescent Health, Medicaid Managed Care, Physical and Behavioral Health Integration, Population Health /by NASHPGovernors across the nation have laid out their priorities for the coming year as part of their State of the State addresses. NASHP summarizes the 44 addresses given to date. Seven governors discussed health insurance exchanges, 13 health care costs, and nine addressed issues related to a culture of health. Individual governors also addressed issues […]
A Day in the Life of Local Care Coordinator Michele Brown in the CareFirst Patient-Centered Medical Home Program
/in Policy Care Coordination, Chronic and Complex Populations, Cost, Payment, and Delivery Reform, Health System Costs, Physical and Behavioral Health Integration, Primary Care/Patient-Centered/Health Home, Quality and Measurement /by NASHP StaffDesigning a successful PCMH program involves policy decisions that create new provider and patient expectations, incentives, and infrastructure to support patient-centered care. An integral feature of the CareFirst PCMH program is the development of a care coordination infrastructure at the central, regional, and local level. Much of the work at the local level is done […]
Transforming the Workforce to Provide Better Chronic Care: The Role of Local Care Coordinators at CareFirst
/in Policy District Of Columbia, Maryland, Virginia Reports Care Coordination, Chronic and Complex Populations, Cost, Payment, and Delivery Reform, Health Coverage and Access, Physical and Behavioral Health Integration, Primary Care/Patient-Centered/Health Home, Quality and Measurement, Workforce Capacity /by Mary Takach and Susan ReinhardPart 6 in the Transforming the Workforce to Provide Better Chronic Care: The Role of Registered Nurses series. Click to see the rest of the series. CareFirst, a commercial insurer serving Maryland, northern Virginia, and the District of Columbia, utilizes local nurse care coordinators to support primary care providers within its patient-centered medical home program. […]
Transforming the Workforce to Provide Better Chronic Care: The Role of a Community Health Nurse in a High-Utilizer Program in Oregon
/in Policy Oregon Reports Behavioral/Mental Health and SUD, Care Coordination, Chronic and Complex Populations, Chronic Disease Prevention and Management, Community Health Workers, Cost, Payment, and Delivery Reform, Health Coverage and Access, Health System Costs, Physical and Behavioral Health Integration, Population Health, Workforce Capacity /by Mary TakachPart 5 in the Transforming the Workforce to Provide Better Chronic Care: The Role of Registered Nurses series. Click to see the rest of the series. Yamhill Community Care Organization (YCCO), one of 16 coordinated care organizations in Oregon, utilizes a community health nurse to manage its Community HUB program, which helps “super-utilizer” patients more […]
A Day in the Life of Community Health Nurse Emily Williamson
/in Policy Oregon Behavioral/Mental Health and SUD, Care Coordination, Chronic and Complex Populations, Chronic Disease Prevention and Management, Community Health Workers, Cost, Payment, and Delivery Reform, Health Coverage and Access, Health System Costs, Medicaid Managed Care, Physical and Behavioral Health Integration, Population Health, Workforce Capacity /by NASHP StaffDeveloping a coordinated care organization in northwest Oregon’s Yamhill County presented an opportunity to build an organization that reflected the community’s vision for high-quality, more efficient, integrated care for Medicaid beneficiaries. When assessing the needs of the community, it became clear to Yamhill Community Care Organization’s (YCCO’s) Clinical Advisory Panel (CAP) that a small percentage […]

For individuals living with complex, often chronic conditions, and their families, palliative care can provide relief from symptoms, improve satisfaction and outcomes, and help address critical mental and spiritual needs during difficult times. Now more than ever, there is growing recognition of the importance of palliative care services for individuals with serious illness, such as advance care planning, pain and symptom management, care coordination, and team-based, multi-disciplinary support. These services can help patients and families cope with the symptoms and stressors of disease, better anticipate and avoid crises, and reduce unnecessary and/or unwanted care. While this model is grounded in evidence that demonstrates improved quality of life, better outcomes, and reduced cost for patients, only a fraction of individuals who could benefit from palliative care receive it. 
























































































































































How States Are Administering Opioid Settlement Funds
/in Behavioral/Mental Health and SUD Featured News Home, Maps Behavioral/Mental Health and SUD, Opioid Use Disorder Chronic and Complex Populations /by Mia AntezzoNASHP Resource Hub: State Strategies to Build and Support Palliative Care
/in Policy Reports, Toolkits Care Coordination, Chronic and Complex Populations, Chronic Disease Prevention and Management, Community Health Workers, Cost, Payment, and Delivery Reform, Featured Policy Home, Health Coverage and Access, Health System Costs, Long-Term Care, Medicaid Managed Care, Palliative Care, Physical and Behavioral Health Integration, Population Health, Workforce Capacity Chronic and Complex Populations /by Kitty Purington, Wendy Fox-Grage and Salom TeshalePalliative care helps individuals with serious illness better manage the symptoms and stressors of disease. These services are interdisciplinary, person- and family-centered, and can help people at any stage of a serious illness.
States are uniquely positioned to influence how Americans think about access, and experience palliative care.