Describes factors that support health care organizations in transitioning from volume- to value-based payment.

Demonstrates that intensive outpatient care programs show promise in reducing utilization and costs and improving patient outcomes for high-need, high-cost populations.

Summarizes different approaches and criteria that can be used to identify patients with complex needs for health system interventions.

Offers a practical framework for safety-net health systems to better identify and segment patients with complex needs, and tailor care models to meet their needs.

A complex care transitions pilot designed through a stakeholder-driven process led to decreased hospital utilization and costs.

Summarizes evidence on how integrated care models affect health and cost outcomes for dually eligible beneficiaries.

Medicare patients with the top five percent in preventable utilization account for almost half of all avoidable Medicare costs.

Integrated health care systems can better support high-risk patients by embedding high-risk patient care within general primary care and mental health care.

Toolkit offers health care stakeholders in rural areas with practical information to support the design, implementation, and evaluation of community paramedicine programs.

Effective complex care measures vary widely and need to be standardized to better align the field of complex care.

The proportion of low-income, frail, and medically complex individuals enrolled in Medicare Advantage is increasing.

Provider-based model identifies patients at highest risk for complications from COVID-19.

Accountable care organizations (ACOs) and tailored care coordination strategies may improve preventable hospitalizations and reduce racial disparities among patients with coexisting physical and mental health conditions.

Community health worker programs can offset program costs through reduced utilization.

Social workers on rural primary care teams may help decrease high-risk veterans’ acute care use.

California’s Whole Person Care pilot can inform cross-sector initiatives to improve care for Medicaid enrollees with complex health and social needs.

Health care systems may need to tailor screening and referral approaches for social needs, as some needs may be less likely to be met by social service organizations.

Highlighted lessons from two recent studies to help guide future program and measurement approaches for complex care management interventions.

Accountable care organizations must address key funding, community partnership, and data sharing requirements to successfully integrate social services into medical care.

Demonstrating return-on-investment to advance effective business relationships between community-based organizations and health care partners.