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.

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.

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.

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

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.

Consumers and staff members of health and social service organizations share their community engagement experiences.

Primary care and alternative payment models that reduce emergency department use and increase access to care for high-need populations share core components for success.

An affordable housing program in Baltimore generates between $1.30-$1.92 of “social return” in the community for every dollar invested annually.

Use of machine learning clustering algorithms revealed 30 distinct subgroups of patients among high-risk veterans, indicating a need for tailored approaches to health care.

Discusses the benefits and challenges of tele-social care and offers practical tips for providers administering telehealth services for social care activities.

Many physicians report low confidence in caring for patients with disability and negative perceptions about quality of life with a disability, which may reflect biased views that potentially contribute to persistent health disparities.

Suggests that community-based organizations are responding to Medicaid redesign efforts that prioritize social determinants of health by adopting practices similar to health care organizations.

Provides an overview of home-based medical care models, the patients that they serve, and their robust evidence base.

Health care organizations can use population-level data sources about the experiences of people with disabilities to improve care.

Study finds that private equity ownership of skilled nursing facilities leads to a significantly higher average mortality rate for residents.

Describes core competencies that convey the essential knowledge, skills, and attitudes of complex care practitioners and teams to improve care for people with complex needs.