While telehealth has the potential to increase access to treatment for opioid use disorder, barriers still exist for patients and providers in receiving and delivering virtual care.

Supports the use of telehealth and technology-assisted services to increase access to care and improve outcomes for people who use drugs.

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.

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.

Dementia care program delivered by an occupational therapist and tailored to the needs of patients and their caregivers shows improved patient quality of life and caregiver well-being.

A community-based care transition and management intervention showed improved outcomes for patients transitioning to outpatient community care following a psychiatric hospitalization.

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.

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.

Advance care planning more than one month prior to death is associated with decreased acute care utilization at the end of life and in-hospital death for people with serious illness.

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.

A randomized controlled trial found Denver’s Housing First program led to positive impacts on health and utilization for individuals experiencing chronic homelessness and frequent periods of incarceration.

Black Medicaid enrollees who spent more days in the emergency department or county jail were less likely than white enrollees to receive medications for opioid use disorder.

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.