Including caregivers in the discharge planning process reduces the risk of hospital readmission for older adults.

Home-based primary care program reduced hospitalizations for older adults with diabetes, especially those with higher levels of medical complexity.

CareMore’s business model identifies high-risk patients and surrounds them with coordinated services

Home visits can reach patients with complex needs before a higher level of care is needed

Details the key considerations for providers considering integrating peer services for behavioral health into their health care organizations.

A new framework outlines four steps to develop care management programs.

Analysis of care models that serve Medicare-only individuals detailing policy barriers to providing uncovered services and supports and proposed strategies to address them.

This resource collects the most innovative initiatives in Medicaid managed care that emerge each year.

Nursing students successfully coach patients with complex needs to avoid ED use.

Examines a unique program that seeks to integrate medical, behavioral health, and social services for dual eligible individuals with serious mental illnesses, substance abuse problems, or disabilities.

A program to help clinics deliver comprehensive care may decrease mortality and hospitalization rates.

This 2016 survey reveals that the health care system is failing people with complex needs

Cost considerations for the expansion of mobile integrated health care and community paramedicine programs.

The staff position of care coordinator is crucial to success.

The Care Transitions Intervention was co-designed with patients and evaluated using randomized trials.

A calculator that can help build and present business case for serving adults with complex needs.

Person-centered preferences can inform approaches to advanced illness care

A home-based palliative care program using an interdisciplinary care team reduces hospital costs and unnecessary health care utilization for Medicare Advantage beneficiaries.

People with multiple chronic conditions and disabilities enrolled in home-based primary care experienced persistent reduced acute care utilization.

By closing gaps in care, a safety-net ACO has reduced medical costs for Medicaid patients with complex needs.