Home-based program provided by a community health and social worker reduces acute care use and improves care for older adults with complex health and social needs.

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

Toolkit details how hospitals and health systems can use patient race, ethnicity, and language data to advance health equity and eliminate disparities.

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

A review of existing literature finds that medical respite care reduces hospital and emergency department visits, increased use of outpatient care, and leads to overall cost savings.

Home-based intensive care model for Medicaid and dually eligible enrollees with complex needs led to positive health outcomes and reduced acute care spending, particularly for individuals with a behavioral health diagnosis.

The 4Ms approach developed for the Age-Friendly Health System model — what matters, medication, mentation, mobility — has a robust evidence base for providing quality care to older adults.

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

Patients with dementia are more likely to be discharged to hospice from hospitals that offer palliative care programs.

Community health worker-led interventions for older adults with complex needs show evidence of improving participant mood and functional outcomes.

Provides an overview of home-based medical care models, the patients that they serve, and their robust evidence base.

Home-based primary care programs enable care teams to gain insights on a variety of social factors that impact older adults’ health, which allows them to better tailor care to meet patient needs.

Health care organizations can use population-level data sources about the experiences of people with disabilities to improve care.

Demonstrates that a program assisting older adults with complex needs in navigating medical and social services may lower acute care utilization.

Describes core competencies that convey the essential knowledge, skills, and attitudes of complex care practitioners and teams to improve care for people with complex needs.

Demonstrates that intensive outpatient care programs show promise in reducing utilization and costs and improving patient outcomes for high-need, high-cost populations.

Offers a practical framework for safety-net health systems to better identify and segment patients with complex needs, and tailor care models to meet their needs.

A complex care transitions pilot designed through a stakeholder-driven process led to decreased hospital utilization and costs.

This case study highlights an accountable care organization’s home-based primary care program for homebound older adults, with early analysis of outcomes showing reduced acute care utilization.

Complex care management program within Next Generation Accountable Care Organizations reduced cost and utilization for high-risk Medicare beneficiaries.