Interdisciplinary care teams, telehealth, and flexible payment models are included as key recommendations to increase access to home-based primary care in rural communities.

Curated collection of research studies highlights the efficacy of services provided by community-based organizations, with a focus on outcomes relevant to health care partners.

An interdisciplinary home-based primary care program for older adults with limited mobility leads to reductions in health care utilization and costs.

Randomized controlled trial of a person-centered housing intervention for older adults shows improved health outcomes for formerly homeless adults living in permanent supportive housing.

This report highlights challenges of network-based contracting between health care entities and community-based organizations and shares tips for successful implementation.

Toolkit provides best practices and practical tools for designing, implementing, and evaluating the impact of community health workers.

Including spiritual care within care management programs in outpatient, managed care, and population health settings can enhance patient care and support the effectiveness of the interdisciplinary care team.

Partnerships between community-based organizations and primary care providers can improve depression care for older adults.

Shared practical implementation considerations that can support health plans and provider groups in developing community-based models of care that use the strengths of social workers and community health workers.

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.

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

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.

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

Program based in affordable housing sites for older adults and people with disabilities has favorable impact on Medicare and Medicaid expenditures and helps residents remain in community settings.

A regional approach to health care transformation.

Examines how home meal delivery programs show promise for reducing the use of costly health care and decreasing spending for dually eligible individuals.