Understand emerging evidence and best practices for implementing community engagement interventions to better meet community needs and improve health equity.
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Displaying 1 - 20 of 106
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
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
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
Building an LGBTQ+ Inclusive PACE Program: Key Learnings on How the Program of All-Inclusive Care for the Elderly (PACE) Model Addresses the Needs of LGBTQ+ Older Adults
Lessons for developing LGBTQ+ inclusive Program of All-Inclusive Care (PACE) programs for older adults.
Brief/Report
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
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
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
The Paramedic Will See You Now: Expanding Access to Community-Based Care for People with Complex Needs
Highlighted two community paramedicine programs in New England and rural North Carolina that serve people with complex needs.
Webinar
Improving Prediction of Long-Term Care Utilization Through Patient-Reported Measures: Cross-Sectional Analysis of High-Need U.S. Veterans Affairs Patients
Information such as patient-reported function and living arrangements can help understand which patients would benefit most from home- and community-based services.
Peer-Reviewed Article
Association of National Expansion of Insurance Coverage of Medically Tailored Meals with Estimated Hospitalizations and Health Care Expenditures in the US
Simulation model estimates that national implementation of medically tailored meal programs for specific populations would achieve over $13.6 billion in cost savings per year.
Peer-Reviewed Article
Adoption of the Household Model Improves Nursing Home Quality
Case study on nursing home adoption of the household model shows positive impacts on quality and resident satisfaction.
Case Example
A Patient-Centered Complex Care Research Agenda
Recommendations for building a stronger, more coordinated, and patient-centered complex care evidence base.
Brief/Report
Quality Measures for Patients at Risk of Adverse Outcomes in the Veterans Health Administration: Expert Panel Recommendations
Recommended set of evidence-based measures for high-quality care for patients with complex needs based on systematic review of relevant measures.
Peer-Reviewed Article