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

Health homes significantly decreased rates of inpatient utilization over two years for adults receiving mental health treatment.

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

A home-based collaborative care model using community health workers shows reductions in depression and increased connection to services for older adults.

A health-plan-administered telehealth care coaching intervention led to long-term cost savings as well as increased behavioral health service use for adults with behavioral health needs and a history of high utilization.

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.

A provider tool that promotes person-centered and equitable care by recognizing and avoiding bias in electronic health record notes.

Resources to help organizations plan and implement medical respite care programs, including program development guides, case examples, and implementation tools.

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

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

Longer participation in a patient-centered medical home is associated with better mental health care for people enrolled in Medicaid with major depressive disorder and multiple chronic conditions.

Evidence-based behavioral intervention in which positive behaviors are reinforced with material incentives may address clinical problems among people receiving medications for opioid use disorder.

Trust, flexible funding, cross-sector support, sustainability, and an explicit focus on structural racism are identified as key components of effective community engagement to advance health equity.

A novel street psychiatry program offers essential mental health support to unsheltered individuals experiencing homelessness.

Randomized controlled trial of a care management intervention shows significant improvement in patient activation and self-rated health and decreased symptoms of depression in patients with complex needs.

Consumers and staff members of health and social service organizations share their community engagement experiences.

A review of existing literature finds that medical respite care reduces hospital and emergency department visits, increased use of outpatient care, and leads to overall cost savings.

Home-based intensive care model for Medicaid and dually eligible enrollees with complex needs led to positive health outcomes and reduced acute care spending, particularly for individuals with a behavioral health diagnosis.

Identifies opportunities to strengthen integrated programs to improve care and support positive health outcomes for dually eligible individuals both during and beyond the pandemic.

Toolkit offers health care stakeholders in rural areas with practical information to support the design, implementation, and evaluation of community paramedicine programs.