Case study describes experiences and lessons in implementing a hospital at home program that first launched in 2023.

Pairing promotores with clinicians increased in-home visits and reduced acute care use and health care costs for homebound older adults.

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.

Policy recommendations to incentivize the adoption of innovative nursing home models through HUD loans.

Case study on nursing home adoption of the household model shows positive impacts on quality and resident satisfaction.

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.

One health plan’s approach to addressing racial and ethnic disparities in medication adherence rates offers insights on levers to address racial inequities.

A "virtual-first" transitional care program with an interdisciplinary care team can support reduced readmissions.

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.

An interdisciplinary team approach can improve care coordination and reduce length of hospital stays for older adults with complex health and social needs.

Describes electronic health record system functionality that automatically identifies patients likely to need technical assistance prior to telehealth visits.

Case study of interdisciplinary primary care program for high-risk patients based at an academic health system offers lessons on program design and implementation.

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

Embedding a health navigator in a senior housing community improved residents’ sense of physical, mental, and social well-being.

Home-based primary care programs made rapid care delivery adaptations in response to the COVID-19 pandemic, and this flexibility may support new opportunities to care for older, medically complex patients safely in their homes.

This case study highlights an accountable care organization’s home-based primary care program for homebound older adults, with early analysis of outcomes showing reduced acute care utilization.

Demonstrating return-on-investment to advance effective business relationships between community-based organizations and health care partners.

How can a community-based organization demonstrate the two-way financial benefits of partnering with a health plan?

Details how two health plans in California developed programs to transition dually eligible members from institutional settings back into their communities.

A model to improve health and quality of life for rural seniors.