Interdisciplinary primary care models can help reduce acute care use for individuals with histories of high emergency department use, homelessness, or substance use disorder.
Patients and community health workers (CHWs) share perspectives on the impact of CHW services provided within a primary care setting to address barriers to equitable care.
Explored how complex care stakeholders can incorporate a multi-factor approach to measure and demonstrate the value of complex care programs for diverse stakeholders.
Varying structures of cross-sector partnerships between health care organizations, social service agencies, and local government bodies have distinct strengths and serve different functions.
Differing patterns of care utilization and mortality outcomes within subgroups of a complex patient population can help inform more targeted care interventions.
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.
An interdisciplinary team approach can improve care coordination and reduce length of hospital stays for older adults with complex health and social needs.
Evidence-based behavioral intervention in which positive behaviors are reinforced with material incentives may address clinical problems among people receiving medications for opioid use disorder.
Longer participation in a patient-centered medical home is associated with better mental health care for people enrolled in Medicaid with major depressive disorder and multiple chronic conditions.