Differing patterns of care utilization and mortality outcomes within subgroups of a complex patient population can help inform more targeted care interventions.

Systematic review of programs to improve care for patients with complex needs details evidence base across multiple settings.

Explored how health care organizations can incorporate a segmentation framework into population health management using simple algorithms.

Segmentation framework with publicly available code files identifies specific and actionable patient cohorts with complex needs.

Global budgets for hospitals reduced expenditures and utilization for some Medicare subpopulations with complex health and social needs, yet disparities existed for some subgroups.

Using segmentation to address clinical and social needs for Medicaid patients with complex needs and costly utilization can improve the effectiveness of complex care programs.

Home-based palliative care program implemented within an accountable care organization created cost savings through reduced hospital admissions and increased hospice length of stay.

This toolkit can support health care organizations in creating the business case for complex care programs.

A street medicine program increased post-hospitalization follow-up care for unsheltered individuals experiencing homelessness in Los Angeles.

A medical respite program for people experiencing homelessness shows evidence of reduced hospital readmissions and emergency department revisits.

An interdisciplinary team approach can improve care coordination and reduce length of hospital stays for older adults with complex health and social needs.

Describes electronic health record system functionality that automatically identifies patients likely to need technical assistance prior to telehealth visits.

Systematic review finds mixed results for health information technology in enhancing coordinated care and improving health outcomes for people with multiple chronic conditions.

Longer participation in a patient-centered medical home is associated with better mental health care for people enrolled in Medicaid with major depressive disorder and multiple chronic conditions.

A cross-sector partnership to enroll older adults experiencing homelessness in permanent supportive housing led to meaningful reductions in health care costs.

Understanding the values of patients with complex health and social needs can help providers improve care.

Evidence-based behavioral intervention in which positive behaviors are reinforced with material incentives may address clinical problems among people receiving medications for opioid use disorder.

CAPABLE, a home-based care program that provides interdisciplinary services for older adults, leads to reductions in disability as well as cost savings.

Trust, flexible funding, cross-sector support, sustainability, and an explicit focus on structural racism are identified as key components of effective community engagement to advance health equity.

Offers practical recommendations to improve telemedicine interventions to be more equitable for diverse populations, particularly those with low incomes.