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

Analytical approach for randomized controlled trials may be valuable for understanding the impact of complex care interventions and the subpopulations that may benefit from them.

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.

Medicaid enrollees in a community health worker program had fewer emergency department visits and more outpatient ambulatory care use than beneficiaries who received usual care.

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.

Resources to help organizations plan and implement medical respite care programs, including program development guides, case examples, and implementation tools.

Community-based care management programs for patients with complex health and social needs have the potential to reduce hospitalizations and inpatient costs.

Patients with complex needs were more satisfied with in-home urgent care delivered by community paramedics than with emergency department urgent care.

Hospital at home services show similar or better outcomes when compared with traditional inpatient care for Medicaid enrollees.

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.

Interdisciplinary primary care models can help reduce acute care use for individuals with histories of high emergency department use, homelessness, or substance use disorder.

Research review finds that incorporating community health workers into primary care reduced A1c levels and improved self-management and satisfaction among older adults with diabetes.

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.

This toolkit shares practical steps and best practices for health care providers and administrators looking to implement telehealth services for their patients.

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

Telehealth interventions that incorporate patient-centered design and culturally tailored solutions are key to improving outcomes impacted by health disparities, a scoping review finds.

Systematic review of programs to improve care for patients with complex needs details evidence base across multiple settings.

This toolkit can support health care organizations in creating the business case for complex care programs.

A street medicine program increased post-hospitalization follow-up care for unsheltered individuals experiencing homelessness in Los Angeles.

A medical respite program for people experiencing homelessness shows evidence of reduced hospital readmissions and emergency department revisits.