Community health worker-led advance care planning and symptom screening program reduced acute care use for patients with advanced stages of cancer.

Medicare beneficiaries with dementia, especially Black and Hispanic patients, often receive poor quality end-of-life care.

Toolkit offers lessons for integrating behavioral health into primary care settings.

Case managers noted establishing trust, fostering mindset changes, and increasing stability and independence can be measures of success when working with people with complex needs.

Natural language processing of patient visit notes can help providers identify social factors that may lead to health care utilization for older adults with multiple chronic conditions.

While the Medicare hospice benefit has historically been designed to meet the needs of patients with cancer, people with dementia and their caregivers experience better outcomes when enrolled in hospice.

A "virtual-first" transitional care program with an interdisciplinary care team can support reduced readmissions.

Summarizes research on the prevalence of social screening in health care settings, validity of social screening tools, and patient and provider perspectives on social screening.

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.

While there is limited research on whether Medicaid home and community-based services are available, accessible, accommodating, and acceptable for marginalized groups, existing evidence shows that there are widespread disparities that policymakers should address.

Peer support specialists can link patients with substance use disorders to treatment, but this study showed disparate outcomes for how one program impacted access to care for Black and white patients.

Report explores the definition and components of street medicine and outreach, as well as provides best practices for delivering this type of care.

Racial disparities in long-term care facilities impact quality of life for residents who are Black, Indigenous, or other persons of color.

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.

Described how health care organizations and community-based organizations can use the ROI Calculator to explore and plan financial arrangements to fund social services for people with complex needs.

Partnerships between community-based organizations and primary care providers can improve depression care for older adults.