Describes the needs of distinct subpopulations within the dually eligible population with highly complex needs, along with opportunities for tailored interventions that may reduce health care spending.

New Mexico’s model to deploy community health workers is now replicated in 12 states.

The National Academy of Medicine offers a synthesis of the evidence for improving care for high-needs patients.

This resource describes the value of navigators for Medicaid beneficiaries with mental illness.

Clinical Nurse Specialists are playing a greater role in palliative care, but evidence on their cost-effectiveness is mixed.

This paper describes competing health care systems can collaborate to improve care for overlapping patient populations.

Including caregivers in the discharge planning process reduces the risk of hospital readmission for older adults.

Home-based primary care program reduced hospitalizations for older adults with diabetes, especially those with higher levels of medical complexity.

CareMore’s business model identifies high-risk patients and surrounds them with coordinated services

Home visits can reach patients with complex needs before a higher level of care is needed

Details the key considerations for providers considering integrating peer services for behavioral health into their health care organizations.

A new framework outlines four steps to develop care management programs.

This resource collects the most innovative initiatives in Medicaid managed care that emerge each year.

Nursing students successfully coach patients with complex needs to avoid ED use.

Cost considerations for the expansion of mobile integrated health care and community paramedicine programs.

The staff position of care coordinator is crucial to success.

Examines a unique program that seeks to integrate medical, behavioral health, and social services for dual eligible individuals with serious mental illnesses, substance abuse problems, or disabilities.

A program to help clinics deliver comprehensive care may decrease mortality and hospitalization rates.

This 2016 survey reveals that the health care system is failing people with complex needs

The Care Transitions Intervention was co-designed with patients and evaluated using randomized trials.