Recommendations for building a stronger, more coordinated, and patient-centered complex care evidence base.

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 patient navigation intervention for people with substance use disorder led to cost savings of over $17,000 per participant after 12 months post-discharge due to reduced inpatient admissions and emergency department visits.

Recommended set of evidence-based measures for high-quality care for patients with complex needs based on systematic review of relevant measures.

Black caregivers of people with dementia share their perspectives on a care coordination intervention.

Louisiana improved Medicaid enrollment and health care access for people reentering communities from state prisons.

Community health worker-led advance care planning and symptom screening program reduced acute care use for patients with advanced stages of cancer.

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.

This study identifies facilitators and barriers of hospital- and community-based harm reduction collaboration efforts and highlights hospital-based opportunities to better serve people who use drugs.

Care management interventions for people transitioning from behavioral health inpatient care may be successful in decreasing readmissions if they address health-related social needs.

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

Virtual collaborative care intervention demonstrates an approach to improve medication adherence and health outcomes.

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.

Behavioral health home model is associated with long-term changes in health services utilization for people with serious behavioral health conditions.