Toolkit offers guidance for corrections and health care professionals on evidence-based interventions to support the reentry needs of people with behavioral health needs.

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.

Insights from patient-level encounter histories can support optimizing care coordination team staffing for high-need patients.

California leveraged Medicaid waiver authority to cover targeted pre-release services with the goal of improving the health of people reentering the community after incarceration.

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

Social and legal services to address health care costs and utilization may be most effective for individuals with moderately high utilization who are less clinically complex.

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

Guidance on developing a reentry program to support Native Americans who are reentering communities from jail or prisons.

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

California’s Whole Person Care pilot can inform cross-sector initiatives to improve care for Medicaid enrollees with complex health and social needs.

A regional approach to health care transformation.

By closing gaps in care, a safety-net ACO has reduced medical costs for Medicaid patients with complex needs.