Resources

Adults with serious mental illness (SMI) are at much greater risk than the general population for cardiovascular disease, and require tailored interventions to address co-occurring cardiovascular risk...
Low-income individuals with diabetes who experience unstable housing and food insecurity are likely to have increased emergency department (ED) visits and hospitalizations. This study evaluated the...
Individuals with serious mental illness (SMI) have high preventable emergency department (ED) usage, often due to poorly managed chronic medical conditions. A North Carolina primary care center...
The coronavirus pandemic intensified the already pressing need for the communication and symptom management expertise of palliative care specialists. Amid the surge of COVID-19 cases in New York City...
Cityblock Health provides care to populations with high rates of social, behavioral, and health risk factors, many of whom are at higher risk for complications from COVID-19. Cityblock developed a...
Complex care programs across the country use varied criteria to identify people with complex health and social needs and measure the effectiveness of subsequent interventions. Greater standardization...
Although health care systems commonly refer individuals with unmet social needs to social service agencies, in some cases, these agencies may not have the capacity to provide adequate assistance. This...
Integrated primary care teams have demonstrated positive impacts on patient care, but less is known about the impact of including social workers on these teams. This study evaluated the addition of...
Whole Person Care (WPC) pilots, under California’s Medicaid Section 1115(a) waiver demonstration, integrate medical, behavioral health, and social needs services to improve the health and wellbeing of...
Health care organizations are increasingly partnering with Area Agencies on Aging (AAAs) to provide social needs support for older adults in the community who are identified with high health risks...
Effective patient-centered case management interventions can potentially improve health and social outcomes for individuals experiencing homelessness or housing instability. This literature review...
To improve health outcomes and reduce health care costs and utilization for people with complex needs, it is important to understand the underlying social and behavioral issues that may be driving...