Including spiritual care within care management programs in outpatient, managed care, and population health settings can enhance patient care and support the effectiveness of the interdisciplinary care team.
Implementation of the Age-Friendly Health Systems approach within a Federally Qualified Health Center can improve patient care process outcomes and improve access to care for rural older adults.
Randomized controlled trial of a home-based primary care program shows some improved outcomes and contributes to evidence base on home-based primary care.
A patient navigation intervention for people with substance use disorder led to cost savings of over $17,000 per participant after 12 months post-discharge due to reduced inpatient admissions and emergency department visits.
A home-based urgent care program for frail, homebound older adults did not reduce emergency department visits, hospitalizations, or total medical expenditure.
Social and legal services to address health care costs and utilization may be most effective for individuals with moderately high utilization who are less clinically complex.
Analytical approach for randomized controlled trials may be valuable for understanding the impact of complex care interventions and the subpopulations that may benefit from them.
A short-term emergency department navigator program helped address acute care utilization for individuals with low baseline utilization through primary care follow up appointments and assistance with social needs.
A collaborative interprofessional dementia care program significantly improved the timeliness of diagnosis compared to traditional clinics and achieved high satisfaction rates among staff, patients, and caregivers.
Medicaid enrollees in a community health worker program had fewer emergency department visits and more outpatient ambulatory care use than beneficiaries who received usual care.
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.