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

A community-based care transition and management intervention showed improved outcomes for patients transitioning to outpatient community care following a psychiatric hospitalization.

A Medicaid health home care management program led to improved diabetes care, benefitting people with co-occurring substance use disorders and diabetes.

Evidence-based intervention at a behavioral health home improved health outcomes for patients with co-occurring type 2 diabetes and serious mental illness.

Personalized patient navigation supports for people with comorbid substance use disorders reduced rates of hospital readmissions and emergency department use.

Provides an overview of home-based medical care models, the patients that they serve, and their robust evidence base.

A randomized clinical trial of an 18-month comprehensive intervention showed significant reductions in cardiovascular disease risk in adults with serious mental illness.

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

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

Randomized controlled trial of a care management intervention offers important lessons for the field of complex care.

Telephone- and web-based dementia care provided through centralized hubs and delivered by an interdisciplinary team can improve outcomes for people with dementia and their caregivers.

Ten common attributes for successful care management programs serving high-need, high-cost populations.

A tool helps providers capture essential information when interviewing people experiencing unsheltered homelessness to support effective treatment planning.

Staff time effort in complex care coordination programs is highly variable depending on patients’ health and social needs.

An analysis of the National Survey of ACOs

Maximizing the impact of outpatient complex case management.

A regional approach to health care transformation.

This resource describes one tool to identify patients most likely to benefit from care management.

Details implementation guidance for the evidence-based Care Ecosystem model, which improves supports for people with dementia and their caregivers.

This resource describes the value of navigators for Medicaid beneficiaries with mental illness.