Downloadable tools, tip sheets, sample forms, and how-to guides on home-based primary care, with a focus on clinical and operational best practices.

Toolkit can help guide implementation of integrated care teams into primary care settings.

Clearly defining characteristics of complex populations is essential for effective complex care intervention design.

Contains practical guides, tools, and other resources for developing complex care programs.

Use of hospital readmission rates to measure quality may be unfair for some accountable care organizations and safety-net providers, since members with complex medical and social needs are a main driver of these rates.

A Comprehensive Medication Management program that employs a remote clinical pharmacist effectively addresses most drug therapy problems in a complex care population.

During the COVID-19 pandemic, Cityblock Health implemented a virtually integrated care management model to maintain continuity of care for patients with complex needs.

A novel street psychiatry program offers essential mental health support to unsheltered individuals experiencing homelessness.

Randomized controlled trial of a care management intervention shows significant improvement in patient activation and self-rated health and decreased symptoms of depression in patients with complex needs.

Featured promising strategies from health systems and payers — including Kaiser Permanente, New York City Health + Hospitals, and CareOregon — for effectively identifying people with complex health and social needs to inform tailored health care interventions for targeted subpopulations.

Profile of a geriatric emergency department model for older adults with complex needs includes sample policies and workflows as well as recommendations to support effective implementation.

Includes patient- and staff-reported measures to help complex care programs better understand the impacts of interventions.

Case studies and lessons from evidence-based interventions to address social isolation and loneliness in older adults.

Brief provides overview of medication therapy management in Medicaid to support members with multiple chronic conditions.

Tool outlines expert recommendations to improve access to medications for opioid use disorder within community pharmacies.

A comprehensive review of state mechanisms to reimburse for community health worker services.

A pharmacist-led substance use disorder intervention improved treatment retention for patients with opioid and alcohol use disorder.

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

Medicare Advantage plans report different barriers to partnering with community-based organizations, but there are strategies to develop effective partnerships.

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