A primary care-based integrated care team supports patients with type 1 or type 2 diabetes in reducing A1c levels.

Health homes significantly decreased rates of inpatient utilization over two years for adults receiving mental health treatment.

Embedded peer navigators provide support and mentorship for people experiencing homelessness, leading to increases in chronic disease screening and referrals.

A home-based collaborative care model using community health workers shows reductions in depression and increased connection to services for older adults.

A health-plan-administered telehealth care coaching intervention led to long-term cost savings as well as increased behavioral health service use for adults with behavioral health needs and a history of high utilization.

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.

Resources to help organizations plan and implement medical respite care programs, including program development guides, case examples, and implementation tools.

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

A street medicine program increased post-hospitalization follow-up care for unsheltered individuals experiencing homelessness in Los Angeles.

Longer participation in a patient-centered medical home is associated with better mental health care for people enrolled in Medicaid with major depressive disorder and multiple chronic conditions.

Randomized controlled trial of a care management intervention shows significant improvement in patient activation and self-rated health and decreased symptoms of depression in patients with complex needs.

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.

Toolkit offers health care stakeholders in rural areas with practical information to support the design, implementation, and evaluation of community paramedicine programs.

Virginia’s comprehensive Medicaid reform for substance use treatment services led to an increase in outpatient and community-based treatment and a decrease in emergency department and inpatient use among beneficiaries with opioid use disorder.

Discharge to medical respite care leads to lower hospital readmission rates among individuals who are frequently admitted to the hospital.

A tool helps providers capture essential information when interviewing people experiencing unsheltered homelessness to support effective treatment planning.

Details the main elements of a hospital-based addiction care consultation team.

This resource describes the value of navigators for Medicaid beneficiaries with mental illness.