Understand emerging evidence and best practices for implementing community engagement interventions to better meet community needs and improve health equity.
All Resources
Topics
Populations
Audiences
Content Types
State
Topics
Populations
Audiences
Content Types
State
Displaying 1 - 20 of 157
A post-hospitalization supplemental home-delivered meals benefit saw significant uptake and high satisfaction among Medicare Advantage members with greater financial or food insecurity.
Peer-Reviewed Article
Understanding the Medicare Physician Fee Schedule Billing Codes For: Community Health Integration, Principal Illness Navigation, and Principal Illness Navigation-Peer Support Services
This toolkit details options for implementing recently introduced Medicare services that address members’ health-related social needs.
Implementation Tool
Bridging the Home-Based Primary Care Gap in Rural Areas
Interdisciplinary care teams, telehealth, and flexible payment models are included as key recommendations to increase access to home-based primary care in rural communities.
Brief/Report
Effect of Discharge Readiness on 30-Day Readmissions Among Older Adults Living with Chronic Conditions
Nurse assessments of discharge readiness for older patients with multiple chronic conditions can help identify patients at high risk for hospital readmission.
Peer-Reviewed Article
Medicare-Medicaid Integrated Care Programs
Curates evidence behind three fully integrated care program models for people who are dually eligible for Medicare and Medicaid, as well as practical strategies that support effective implementation of these programs.
Collection
December 2023
Improving Nursing Home Care Quality
Curates evidence on improving nursing home care quality and explores practical tools that support effective implementation of care and services that are more person-centered and improve outcomes for nursing home residents.
Collection
November 2023
Telehealth Outcomes and Impact on Care Delivery: A Review of Evidence
Report summarizes the evidence on outcomes for patients participating in various telehealth delivered services, including different modalities, such as telephone and video.
Brief/Report
Association Between ICD-10 Codes for Social Needs and Subsequent Emergency and Inpatient Use
An association between Z code assignment and increased emergency and inpatient health care utilization presents opportunities for targeted interventions that address patients' social needs.
Peer-Reviewed Article
Cost Reduction and Utilization Patterns in a Medicare Accountable Care Organization Using Home-Based Palliative Care Services
A home-based palliative care program leads to reductions in hospitalizations and total cost of care, along with an increase in the use of hospice care.
Peer-Reviewed Article
Addressing Healthcare Utilization and Costs for Older Adults with Limited Mobility Through a Multidisciplinary Home-Based Primary Care Program
An interdisciplinary home-based primary care program for older adults with limited mobility leads to reductions in health care utilization and costs.
Peer-Reviewed Article
Scaling Primary Care Social Needs Screening and Referrals in New York City’s Safety-Net Health System
An overview of NYC Health + Hospital’s implementation of a primary care-based social needs screening and referral program, including key implementation challenges and success factors.
Case Example
A Pilot Randomized Controlled Trial of CAPABLE in Permanent Supportive Housing for Formerly Homeless Adults
Randomized controlled trial of a person-centered housing intervention for older adults shows improved health outcomes for formerly homeless adults living in permanent supportive housing.
Peer-Reviewed Article
Community Health Worker Programs in Primary Care
Curates recent evidence behind community health worker programs that support people with complex health and social needs, as well as practical strategies to support effective implementation of these programs.
Collection
April 2023
Lifting the Veil How Networks Form Operate Struggle and Succeed
This report highlights challenges of network-based contracting between health care entities and community-based organizations and shares tips for successful implementation.
Brief/Report
Evaluating a Care Management Program for Dual-Eligible Beneficiaries: Evidence from Rhode Island
Community health worker-led program associated with reduced acute care utilization and lower Medicaid and total costs for dually eligible individuals.
Brief/Report
Making the Business Case for Value-Based Dementia Care
Opportunities for identifying the financial value of dementia care to support positive return on investment.
Peer-Reviewed Article
The Role of Community Health Workers in the Health and Well-Being of Vulnerable Older Adults During the COVID-19 Pandemic
A telephone-based community health worker program offered critical supports for older adults during the COVID-19 pandemic.
Peer-Reviewed Article
Partnering with Community Health Workers/Promotores to Adapt, Deliver, and Evaluate a Home-Based Collaborative Care Model to Improve Access to Quality Depression Care for Older Latino Adults
A home-based collaborative care model using community health workers shows reductions in depression and increased connection to services for older adults.
Peer-Reviewed Article
Addressing Social Isolation and Loneliness Among Older Dually Eligible Individuals
Toolkit offers recommendations and examples for screening and interventions that support social connectivity of older adults.
Implementation Tool