A home-based primary care program for homebound older adults leads to reductions in health care utilization and overall cost savings.

A care management model designed to center patients’ health priorities shows promising results.

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.

One health plan’s approach to addressing racial and ethnic disparities in medication adherence rates offers insights on levers to address racial inequities.

Case managers noted establishing trust, fostering mindset changes, and increasing stability and independence can be measures of success when working with people with complex needs.

Shared practical implementation considerations that can support health plans and provider groups in developing community-based models of care that use the strengths of social workers and community health workers.

Home-based primary care did not decrease hospitalizations for people with dementia, but it did result in more patient- and family-centered end-of-life care.

An interdisciplinary team approach can improve care coordination and reduce length of hospital stays for older adults with complex health and social needs.

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.

Embedding a health navigator in a senior housing community improved residents’ sense of physical, mental, and social well-being.

Presents tools and tips frontline care management staff to address high-risk patients’ unmet social health needs during the COVID-19 pandemic.

This case study highlights an accountable care organization’s home-based primary care program for homebound older adults, with early analysis of outcomes showing reduced acute care utilization.

Complex care management program within Next Generation Accountable Care Organizations reduced cost and utilization for high-risk Medicare beneficiaries.

Details how two health plans in California developed programs to transition dually eligible members from institutional settings back into their communities.

Impact of social needs navigation program on future utilization of patients with prior high utilization.

A unique cross-sector partnership involving health care, police, and emergency services improved health care utilization in this rural health system pilot.

Improving Dementia Care

This guide for state leaders offers lessons about state-level approaches to complex care.

The VA shares lessons on workforce learning and development.

CareMore’s business model identifies high-risk patients and surrounds them with coordinated services