Interdisciplinary primary care models can help reduce acute care use for individuals with histories of high emergency department use, homelessness, or substance use disorder.

Medical notes about Black patients were more than twice as likely to contain stigmatizing language compared to white patients.

Toolkit offers lessons for engaging people with lived experience in human services initiatives.

Accountable care organization leaders share perspectives on payment mechanisms used with social service organizations, challenges experienced, and the impacts of these partnerships.

Explored how complex care stakeholders can incorporate a multi-factor approach to measure and demonstrate the value of complex care programs for diverse stakeholders.

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

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.

Global budgets for hospitals reduced expenditures and utilization for some Medicare subpopulations with complex health and social needs, yet disparities existed for some subgroups.

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.

This toolkit can support health care organizations in creating the business case for complex care programs.

Describes electronic health record system functionality that automatically identifies patients likely to need technical assistance prior to telehealth visits.

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.

Case study of interdisciplinary primary care program for high-risk patients based at an academic health system offers lessons on program design and implementation.

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

Downloadable tools, tip sheets, sample forms, and how-to guides on home-based primary care, with a focus on clinical and operational best practices.

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

Use of hospital readmission rates to measure quality may be unfair for some accountable care organizations and safety-net providers, since members with complex medical and social needs are a main driver of these rates.

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