Clearly defining characteristics of complex populations is essential for effective complex care intervention design.

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

During the COVID-19 pandemic, Cityblock Health implemented a virtually integrated care management model to maintain continuity of care for patients with complex needs.

Profile of a geriatric emergency department model for older adults with complex needs includes sample policies and workflows as well as recommendations to support effective implementation.

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

Case studies and lessons from evidence-based interventions to address social isolation and loneliness in older adults.

A care coordination and palliative care intervention for adults with complex needs was associated with significantly reduced short-term mortality.

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.

Disparities in transitional care training for caregivers of older adults based on race or financial status demonstrate need for changes in discharge processes and strategies to address bias.

Home-based program provided by a community health and social worker reduces acute care use and improves care for older adults with complex health and social needs.

Creating clinically meaningful profiles of patients with medically complex needs can support the delivery of more tailored interventions.

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

Toolkit details how hospitals and health systems can use patient race, ethnicity, and language data to advance health equity and eliminate disparities.

Literature review examines the roles and contributions of community health workers in improving dementia care.

Home-based intensive care model for Medicaid and dually eligible enrollees with complex needs led to positive health outcomes and reduced acute care spending, particularly for individuals with a behavioral health diagnosis.

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.

The 4Ms approach developed for the Age-Friendly Health System model — what matters, medication, mentation, mobility — has a robust evidence base for providing quality care to older adults.

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

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.