Segmentation framework with publicly available code files identifies specific and actionable patient cohorts with complex needs.

Global budgets for hospitals reduced expenditures and utilization for some Medicare subpopulations with complex health and social needs, yet disparities existed for some subgroups.

Using segmentation to address clinical and social needs for Medicaid patients with complex needs and costly utilization can improve the effectiveness of complex care programs.

Literature review of nearly 90 articles on home-based primary care identifies themes for enhancing care quality.

Looked at the provider and payer relationship and discussed how successful partnerships between these two stakeholders can create sustainable and efficacious home and community based palliative care programs.

This toolkit can support health care organizations in creating the business case for complex care programs.

Care team models with more nurse practitioners and physician assistants than physicians are associated with increased primary care and geriatrics services provision and reduced labor costs.

Report analyzes evidence on integrated care models in comparison to non-integrated Medicare Advantage plans.

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

Describes electronic health record system functionality that automatically identifies patients likely to need technical assistance prior to telehealth visits.

A cross-sector partnership to enroll older adults experiencing homelessness in permanent supportive housing led to meaningful reductions in health care costs.

Understanding the values of patients with complex health and social needs can help providers improve care.

Analysis of 310 health systems showed gaps in opioid receipt between Black and white patients, especially on dosage, which may be related to racial bias among clinicians.

CAPABLE, a home-based care program that provides interdisciplinary services for older adults, leads to reductions in disability as well as cost savings.

Offers practical recommendations to improve telemedicine interventions to be more equitable for diverse populations, particularly those with low incomes.

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

Person-centered integrated care models designed to respond to the priorities of people dually eligible for Medicare and Medicaid are more likely to increase and sustain enrollment.

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

Clearly defining characteristics of complex populations is essential for effective complex care intervention design.

Contains practical guides, tools, and other resources for developing complex care programs.