Recommendations for policymakers, health plans, and providers on implementing medically tailored meals programs.

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.

The Patient-Centered Medical Home model shows positive impacts in health center settings including improved quality of care.

Community health worker interventions are effective for improving health behaviors and outcomes and reducing health care costs for people with chronic disease.

Findings from a literature review and state interviews share experiences and outcomes of implementing Medicaid accountable care organization programs.

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

Well-designed bidirectional community and referral pathways may help bridge the community-clinic divide.

Toolkit provides best practices and practical tools for designing, implementing, and evaluating the impact of community health workers.

This report outlines practical approaches to guide health systems in more meaningfully involving community members and being more accountable to the communities they serve.

Highlighted how Denver Health, a large health system in Colorado, is integrating a trauma- and resilience-informed approach into organization-wide policy and practice.

Pharmacist-led telephonic motivational interviewing intervention increased medication adherence among an older adult population with chronic disease.

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.

Medicaid health plan-led community health worker program showed moderate evidence for increased outpatient care and primary care use.

Colorado and Virginia’s Medicaid programs provide examples of states engaging communities to improve health outcomes.

Leveraging Medicaid State Plan Amendments can support sustainable funding approaches for community health workers.

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.

Primary care-based interventions that integrate community health and social care services can reduce the rate of avoidable hospitalizations.

Toolkit offers recommendations and examples for screening and interventions that support social connectivity of older adults.