Varying structures of cross-sector partnerships between health care organizations, social service agencies, and local government bodies have distinct strengths and serve different functions.

Home-based primary care did not decrease hospitalizations for people with dementia, but it did result in more patient- and family-centered end-of-life care.

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

Systematic review of programs to improve care for patients with complex needs details evidence base across multiple settings.

Explored how health care organizations can incorporate a segmentation framework into population health management using simple algorithms.

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

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.

Dementia care program delivered by an occupational therapist and tailored to the needs of patients and their caregivers shows improved patient quality of life and caregiver well-being.

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.

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

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.

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

A patient intervention that supported outpatient addiction treatment with destigmatized conversations about substance use between patients and primary care providers showed long-term benefits.

Peer providers with lived experiences of substance use and mental health disorders can help improve patient outcomes and play a unique role in the behavioral health workforce.

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

Includes patient- and staff-reported measures to help complex care programs better understand the impacts of interventions.

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