Research review finds Medicaid accountable care organizations show promise for increasing primary care visits and reducing hospital admissions, with mixed results for quality, outcomes, and costs.

Interdisciplinary care teams, telehealth, and flexible payment models are included as key recommendations to increase access to home-based primary care in rural communities.

This webinar featured a rural Pennsylvania partnership and its experience implementing trauma-informed care across a network of providers.

Pharmacy liaison-patient navigator programs offer a promising approach to streamline screening and system navigation efforts related to health-related social needs.

An interdisciplinary home-based primary care program for older adults with limited mobility leads to reductions in health care utilization and costs.

Having onsite care coordinators may significantly improve the quality of patient care, while centralized coordination is associated with increased information sharing.

A program to connect Medicaid ACO enrollees with nutrition and housing-related services demonstrated early indications of effectiveness.

Integrated care in MassHealth ACOs varies greatly across primary care practice type and is associated with greater ability to improve care quality and advance health equity.

Community health worker interventions are effective for improving health behaviors and outcomes and reducing health care costs for people with chronic disease.

Findings from a literature review and state interviews share experiences and outcomes of implementing Medicaid accountable care organization programs.

Highlighted two community paramedicine programs in New England and rural North Carolina that serve people with complex needs.

An intensive care management intervention led to over $23,000 savings per year in total medical expenses for participating high-risk Medicaid ACO enrollees.

Including spiritual care within care management programs in outpatient, managed care, and population health settings can enhance patient care and support the effectiveness of the interdisciplinary care team.

A "virtual-first" transitional care program with an interdisciplinary care team can support reduced readmissions.

A short-term emergency department navigator program helped address acute care utilization for individuals with low baseline utilization through primary care follow up appointments and assistance with social needs.

Described how health care organizations and community-based organizations can use the ROI Calculator to explore and plan financial arrangements to fund social services for people with complex needs.

Describes a primary care organization’s approach to using machine learning versus provider judgement to assign primary care visit frequency and better identify future risk of hospitalization and medical cost.

Accountable care organization leaders share perspectives on payment mechanisms used with social service organizations, challenges experienced, and the impacts of these partnerships.

Explored how complex care stakeholders can incorporate a multi-factor approach to measure and demonstrate the value of complex care programs for diverse stakeholders.