Recommended set of evidence-based measures for high-quality care for patients with complex needs based on systematic review of relevant measures.

A home-based urgent care program for frail, homebound older adults did not reduce emergency department visits, hospitalizations, or total medical expenditure.

This description and application of a valid and reliable measure of equity of inpatient hospital experiences can help hospitals collect better data to meaningfully promote high-quality equitable care.

Includes information and tools for palliative care program leaders on making the case for palliative care services in public hospitals.

A jail screening and post-release permanent supportive housing program is associated with fewer inpatient visits, more mental health outpatient visits, and overall cost savings.

A telehealth addiction consult service program for hospitalized patients with substance use disorders is as effective as in-person consults.

Patients with higher ACEs scores or positive PTSD screenings felt stress when seeking medical care, but indicated trauma-informed treatment approaches would relieve this stress.

Black caregivers of people with dementia share their perspectives on a care coordination intervention.

Nurses and members of fully staffed interdisciplinary care teams are more likely to use patient identification and care management tools.

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.

Louisiana improved Medicaid enrollment and health care access for people reentering communities from state prisons.

Community health worker-led advance care planning and symptom screening program reduced acute care use for patients with advanced stages of cancer.

Medicare beneficiaries with dementia, especially Black and Hispanic patients, often receive poor quality end-of-life care.

Toolkit offers lessons for integrating behavioral health into primary care settings.

Case managers noted establishing trust, fostering mindset changes, and increasing stability and independence can be measures of success when working with people with complex needs.

While the Medicare hospice benefit has historically been designed to meet the needs of patients with cancer, people with dementia and their caregivers experience better outcomes when enrolled in hospice.

A "virtual-first" transitional care program with an interdisciplinary care team can support reduced readmissions.

Summarizes research on the prevalence of social screening in health care settings, validity of social screening tools, and patient and provider perspectives on social screening.

Analytical approach for randomized controlled trials may be valuable for understanding the impact of complex care interventions and the subpopulations that may benefit from them.

Peer support specialists can link patients with substance use disorders to treatment, but this study showed disparate outcomes for how one program impacted access to care for Black and white patients.