Providing virtual case mentoring to outpatient care teams may reduce unnecessary hospital and emergency department visits for high-need, high-cost patients.

Connecting complex care teams with specialists through videoconferencing can increase their effectiveness in caring for high-need high-cost patients.

Describes how health care providers and their correctional agency partners can design medications for addiction treatment programs for people with opioid use disorder in jails and prisons.

Discharge to medical respite care leads to lower hospital readmission rates among individuals who are frequently admitted to the hospital.

Explored innovative integrated health plan approaches to improve care transitions. Health plans featured in the webinar participate in Promoting Integrated Care for Dual Eligibles (PRIDE), a project to advance health plan strategies for providing high-quality care for dually eligible beneficiaries.

Telephone- and web-based dementia care provided through centralized hubs and delivered by an interdisciplinary team can improve outcomes for people with dementia and their caregivers.

Tools, tips, and vignettes for incorporating telehealth into home-based primary care models.

Details how two health plans in California developed programs to transition dually eligible members from institutional settings back into their communities.

Implementing a trauma-informed approach in primary care.

Ten common attributes for successful care management programs serving high-need, high-cost populations.

Lower inpatient admissions rates in a transitional care intervention.

Moving patients out of the ED and into community support.

A permanent supportive housing program did not improve most measures related to physical health for individuals experiencing chronic homelessness, but did improve access to and trust in primary care.

An interdisciplinary, hospital-based addiction medicine consultation team improved substance use disorder treatment engagement after hospitalization.

A tool helps providers capture essential information when interviewing people experiencing unsheltered homelessness to support effective treatment planning.

The benefits of a transitional care program.

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.

This toolkit details the benefits of home-based primary care to help providers demonstrate the need for these programs.