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

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

Addressing care coordination and medication-related needs within a mobile integrated health care-community paramedicine program leads to a reduction in hospital readmissions.

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

Well-designed bidirectional community and referral pathways may help bridge the community-clinic divide.

Highlighted two community paramedicine programs in New England and rural North Carolina that serve people with complex needs.

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.

An intensive care management intervention led to over $23,000 savings per year in total medical expenses for participating high-risk Medicaid ACO enrollees.

A short-term emergency department navigator program helped address acute care utilization for individuals with low baseline utilization through primary care follow up appointments and assistance with social needs.

Describes a primary care organization’s approach to using machine learning versus provider judgement to assign primary care visit frequency and better identify future risk of hospitalization and medical cost.

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

Patients and community health workers (CHWs) share perspectives on the impact of CHW services provided within a primary care setting to address barriers to equitable care.

Systematic review of programs to improve care for patients with complex needs details evidence base across multiple settings.

Case study of interdisciplinary primary care program for high-risk patients based at an academic health system offers lessons on program design and implementation.

Downloadable tools, tip sheets, sample forms, and how-to guides on home-based primary care, with a focus on clinical and operational best practices.

A Comprehensive Medication Management program that employs a remote clinical pharmacist effectively addresses most drug therapy problems in a complex care population.

Primary care and alternative payment models that reduce emergency department use and increase access to care for high-need populations share core components for success.

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.