A health plan-led telepsychiatry program for older adults can address the shortage of psychiatrists to improve outcomes related to depression and access to mental health care.

Using the Project ECHO model to train rural providers on the Age-Friendly Health Systems Framework demonstrated successful process outcomes.

An intensive care management intervention led to over $23,000 savings per year in total medical expenses for participating high-risk Medicaid ACO enrollees.

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.

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

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.

State investments in enhanced primary care for older and chronically ill individuals recently released from incarceration yielded a $2.55 return on investment for Medicaid and criminal justice combined.

Primary care medical home improved use of preventive services, chronic illness care, care experience, psychotic symptoms, and mental health-related quality of life for people with serious mental illness.

Describes a primary care organization’s approach to using machine learning versus provider judgement to assign primary care visit frequency and better identify future risk of hospitalization and medical cost.

Behavioral health home model is associated with long-term changes in health services utilization for people with serious behavioral health conditions.

Interdisciplinary primary care models can help reduce acute care use for individuals with histories of high emergency department use, homelessness, or substance use disorder.

Patients and community health workers (CHWs) share perspectives on the impact of CHW services provided within a primary care setting to address barriers to equitable care.

Home-based primary care did not decrease hospitalizations for people with dementia, but it did result in more patient- and family-centered end-of-life care.

Systematic review of programs to improve care for patients with complex needs details evidence base across multiple settings.

Case study of interdisciplinary primary care program for high-risk patients based at an academic health system offers lessons on program design and implementation.

Strategies, challenges, and opportunities in supporting the implementation and sustainability of community paramedicine programs in rural communities.

Downloadable tools, tip sheets, sample forms, and how-to guides on home-based primary care, with a focus on clinical and operational best practices.

Toolkit can help guide implementation of integrated care teams into primary care settings.

A Comprehensive Medication Management program that employs a remote clinical pharmacist effectively addresses most drug therapy problems in a complex care population.