Accountable care organizations must address key funding, community partnership, and data sharing requirements to successfully integrate social services into medical care.
Among high-cost Medicare enrollees, those who are seriously ill, frail, and/or had a serious mental illness experience the most potentially preventable spending.
Providing virtual case mentoring to outpatient care teams may reduce unnecessary hospital and emergency department visits for high-need, high-cost patients.
A unique cross-sector partnership involving health care, police, and emergency services improved health care utilization in this rural health system pilot.
When identifying patients with complex health needs for interventions, algorithms that rely on cost data as a proxy for health status may lead to under-identification of Black patients.
Telehealth interventions had similar outcomes to in-person care for different services and populations, but did not consistently impact utilization such as physician or emergency department visits.