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

California community paramedicine and triage to alternative destination programs lead to more coordinated care and reductions in emergency department visits and hospital readmissions.

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.

A substance use navigator program embedded in emergency departments of an urban health system increased rates of treatment engagement post-discharge.

An outpatient addiction treatment program intervention to facilitate connections to primary care improved patient health care engagement.

A patient navigation intervention for people with substance use disorder led to cost savings of over $17,000 per participant after 12 months post-discharge due to reduced inpatient admissions and emergency department visits.

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

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

A community-based care transition and management intervention showed improved outcomes for patients transitioning to outpatient community care following a psychiatric hospitalization.

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.

Strategies, challenges, and opportunities in supporting the implementation and sustainability of community paramedicine programs in rural communities.

A pharmacist-led substance use disorder intervention improved treatment retention for patients with opioid and alcohol use disorder.

Personalized patient navigation supports for people with comorbid substance use disorders reduced rates of hospital readmissions and emergency department use.

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.

Patients with dementia are more likely to be discharged to hospice from hospitals that offer palliative care programs.

Initiative successfully implemented several evidence-based and promising addiction care models across multiple medical settings, including an inpatient addiction consult team, a low-threshold bridge clinic, peer recovery coaches, and office-based addiction treatment nurses.

A complex care transitions pilot designed through a stakeholder-driven process led to decreased hospital utilization and costs.

A jail-based methadone treatment program is shown to reduce reincarnation and lead to overall cost savings.