Nurse assessments of discharge readiness for older patients with multiple chronic conditions can help identify patients at high risk for hospital readmission.

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

A home-based primary care program for homebound older adults leads to reductions in health care utilization and overall cost savings.

A care management model designed to center patients’ health priorities shows promising results.

Recommendations to inform the design and implementation of a new Medicaid Advisory Committee.

Rethinking eligibility, beyond cost and utilization, offers a more equitable approach to identify high-need individuals for care management.

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.

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

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.

One health plan’s approach to addressing racial and ethnic disparities in medication adherence rates offers insights on levers to address racial inequities.

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.

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.

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.

Study details permanent supportive housing program implementation and how this impacts outcomes and costs.

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

A medical respite program for people experiencing homelessness shows evidence of reduced hospital readmissions and emergency department revisits.

An interdisciplinary team approach can improve care coordination and reduce length of hospital stays for older adults with complex health and social needs.

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.

This case study highlights an accountable care organization’s home-based primary care program for homebound older adults, with early analysis of outcomes showing reduced acute care utilization.

Complex care management program within Next Generation Accountable Care Organizations reduced cost and utilization for high-risk Medicare beneficiaries.