North Carolina Medicaid’s Healthy Opportunities Pilot shows reductions in emergency department visits and overall health care costs.

Analysis of a produce prescription and nutrition counseling program show promising results and key implementation insights.

A community health worker initiative embedded in an urban health system led to a significant number of primary care patients receiving services to address their health-related social needs.

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

Evaluation of a diabetes-focused medically tailored meals pilot demonstrates improved health outcomes and provides examples of key implementation tools.

A community health worker-led program for formerly homelessness individuals living in permanent supportive housing increased food security and social connectedness.

A primary care-based integrated care team supports patients with type 1 or type 2 diabetes in reducing A1c levels.

This tool can support health care and community-based organizations in building sustainable cross-sector partnerships.

Curated collection of research studies highlights the efficacy of services provided by community-based organizations, with a focus on outcomes relevant to health care partners.

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

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

This webinar highlighted one successful CBO-health plan partnership model to explore why they entered into a partnership, how they put their contract into practice, and outcomes of the partnership so far.

Insights from patient-level encounter histories can support optimizing care coordination team staffing for high-need patients.

An overview of NYC Health + Hospital’s implementation of a primary care-based social needs screening and referral program, including key implementation challenges and success factors.

A county health department, in collaboration with community-based organizations, conducts community listening sessions to identify priorities for health equity policies.

A guide for health care organizations on evidence-based strategies to implement food and nutrition security programs.

Recommendations for policymakers, health plans, and providers on implementing medically tailored meals programs.

Well-designed bidirectional community and referral pathways may help bridge the community-clinic divide.

Embedded peer navigators provide support and mentorship for people experiencing homelessness, leading to increases in chronic disease screening and referrals.

Summarizes evidence on costs of health-related social needs interventions and their impact on utilization and cost of care to inform ROI Calculator users.