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

Examines how home meal delivery programs show promise for reducing the use of costly health care and decreasing spending for dually eligible individuals.

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

Indicates that a community-based nurse care management model reduced all-cause mortality for older adults with chronic conditions.

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

Using community health workers can reduce hospitalizations in high-risk patients.

Highlighted innovations adopted by PACE organizations during the pandemic to provide care for older adults with complex needs.

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

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.

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

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

Complex care management program for high-need, high-cost Medicaid patients demonstrates substantially lower spending and inpatient utilization.

Providing virtual case mentoring to outpatient care teams may reduce unnecessary hospital and emergency department visits for high-need, high-cost patients.

Connecting complex care teams with specialists through videoconferencing can increase their effectiveness in caring for high-need high-cost patients.

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

Explored innovative integrated health plan approaches to improve care transitions. Health plans featured in the webinar participate in Promoting Integrated Care for Dual Eligibles (PRIDE), a project to advance health plan strategies for providing high-quality care for dually eligible beneficiaries.

The benefits of a transitional care program.

Lower inpatient admissions rates in a transitional care intervention.

The benefits of home-based primary care.