Resources

A telephone-based social needs screening, referral, and navigation program that focused on patients with predicted high utilization within the Kaiser Permanente Southern Cal

Providing supportive housing for individuals experiencing homelessness who are identified as active substance users resulted in lower rates of SUD-related ED visits and hosp

This resource describes a quasi-experimental study evaluating the effect of a transitional care program that involved rapid primary care follow-up

This resource used national survey data from physician practices and ACOs, paired with qualitative interviews, to learn about home visiting programs.

This resource describes and evaluates a new specialist pharmacy service, called the integrated care clinical pharmacist.

At Northwestern Medical Group in Chicago, a patient-centered transitional care intervention serving patients with complex health needs that lack a usual source of care was f

This resource identifies challenges faced by older adults from racial and ethnic minorities, and proposes several strategies to address them.

This resource describes a randomized controlled trial to evaluate the effects of a case management intervention called V1SAGES (Vulnerable Patients in Primary Care: Nurse Ca

This resource describes an effort to apply a learning health systems approach to reducing ED utilization.

This resource is a study evaluating an alternative in-hospital assessment to determine the need for continuing care after discharge.

This resource is a study undertaken to understand the experiences of older adults living in community settings with multiple chronic conditions.

This resource describes four care management models that ACOs are using for individuals with complex needs.