Shared practical implementation considerations that can support health plans and provider groups in developing community-based models of care that use the strengths of social workers and community health workers.
Home-based program provided by a community health and social worker reduces acute care use and improves care for older adults with complex health and social needs.
Complex care management program within Next Generation Accountable Care Organizations reduced cost and utilization for high-risk Medicare beneficiaries.
Details how two health plans in California developed programs to transition dually eligible members from institutional settings back into their communities.