Describes core competencies that convey the essential knowledge, skills, and attitudes of complex care practitioners and teams to improve care for people with complex needs.
Details funding opportunities and successful approaches in the adoption of evidence-based health promotion and disease prevention programs within community-based organizations.
Identifies opportunities to strengthen integrated programs to improve care and support positive health outcomes for dually eligible individuals both during and beyond the pandemic.
Offers a practical framework for safety-net health systems to better identify and segment patients with complex needs, and tailor care models to meet their needs.
This case study highlights an accountable care organization’s home-based primary care program for homebound older adults, with early analysis of outcomes showing reduced acute care utilization.
Toolkit offers health care stakeholders in rural areas with practical information to support the design, implementation, and evaluation of community paramedicine programs.
Poses key questions to help states new to Medicare-Medicaid integration assess readiness for integration and select an achievable integration approach.
Health care systems may need to tailor screening and referral approaches for social needs, as some needs may be less likely to be met by social service organizations.
Accountable care organizations must address key funding, community partnership, and data sharing requirements to successfully integrate social services into medical care.