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

Contains practical guides, tools, and other resources for developing complex care programs.

Use of hospital readmission rates to measure quality may be unfair for some accountable care organizations and safety-net providers, since members with complex medical and social needs are a main driver of these rates.

A novel street psychiatry program offers essential mental health support to unsheltered individuals experiencing homelessness.

Includes patient- and staff-reported measures to help complex care programs better understand the impacts of interventions.

A longitudinal study found that members of recovery community centers had increased rates of substance use abstinence, psychological well-being, and quality of life after three months of engagement.

A comprehensive review of state mechanisms to reimburse for community health worker services.

A pharmacist-led substance use disorder intervention improved treatment retention for patients with opioid and alcohol use disorder.

Evidence-based intervention at a behavioral health home improved health outcomes for patients with co-occurring type 2 diabetes and serious mental illness.

Personalized patient navigation supports for people with comorbid substance use disorders reduced rates of hospital readmissions and emergency department use.

Over 14 years, individuals experiencing chronic homelessness enrolled in a permanent supportive housing program had low housing retention and high mortality.

A permanent supportive housing program reduced emergency department visits within the first six months of placement but showed neutral effects on total cost of care and primary care utilization for Medicaid enrollees.

Consumers and staff members of health and social service organizations share their community engagement experiences.

Primary care and alternative payment models that reduce emergency department use and increase access to care for high-need populations share core components for success.

Creating clinically meaningful profiles of patients with medically complex needs can support the delivery of more tailored interventions.

An affordable housing program in Baltimore generates between $1.30-$1.92 of “social return” in the community for every dollar invested annually.

Literature review examines the roles and contributions of community health workers in improving dementia care.

Use of machine learning clustering algorithms revealed 30 distinct subgroups of patients among high-risk veterans, indicating a need for tailored approaches to health care.

Medication management interventions that support caregivers of people with dementia at care transitions can help reduce readmissions, caregiver burden, and use of high-risk medication.

Discusses the benefits and challenges of tele-social care and offers practical tips for providers administering telehealth services for social care activities.