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.

California community paramedicine and triage to alternative destination programs lead to more coordinated care and reductions in emergency department visits and hospital readmissions.

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 primary care practice redesigned its social needs screening and patient triage process to allow specialized staff to spend more time supporting patients with more intensive housing needs.

This resource guide outlines the value case for health plans to partner with community-based organizations for social care benefits.

The community care hub model can support facilitating strong partnerships between community-based organizations and health care organizations.

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

This report highlights challenges of network-based contracting between health care entities and community-based organizations and shares tips for successful implementation.

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

Described how health care organizations and community-based organizations can use the ROI Calculator to explore and plan financial arrangements to fund social services for people with complex needs.

Partnerships between health care organizations and AAAs can benefit from a clear understanding of internal capabilities and external environmental factors.

Accountable care organization leaders share perspectives on payment mechanisms used with social service organizations, challenges experienced, and the impacts of these partnerships.