Medicaid health plan-led community health worker program showed moderate evidence for increased outpatient care and primary care use.

Toolkit offers recommendations and examples for screening and interventions that support social connectivity of older adults.

Highlighted two community paramedicine programs in New England and rural North Carolina that serve people with complex needs.

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

Social and legal services to address health care costs and utilization may be most effective for individuals with moderately high utilization who are less clinically complex.

Resources to help organizations plan and implement medical respite care programs, including program development guides, case examples, and implementation tools.

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

Interdisciplinary primary care models can help reduce acute care use for individuals with histories of high emergency department use, homelessness, or substance use disorder.

Research review finds that incorporating community health workers into primary care reduced A1c levels and improved self-management and satisfaction among older adults with diabetes.

Patients and community health workers (CHWs) share perspectives on the impact of CHW services provided within a primary care setting to address barriers to equitable care.

Explored how complex care stakeholders can incorporate a multi-factor approach to measure and demonstrate the value of complex care programs for diverse stakeholders.

A street medicine program increased post-hospitalization follow-up care for unsheltered individuals experiencing homelessness in Los Angeles.

A medical respite program for people experiencing homelessness shows evidence of reduced hospital readmissions and emergency department revisits.

CAPABLE, a home-based care program that provides interdisciplinary services for older adults, leads to reductions in disability as well as cost savings.

Literature review examines the roles and contributions of community health workers in improving dementia care.

A review of existing literature finds that medical respite care reduces hospital and emergency department visits, increased use of outpatient care, and leads to overall cost savings.

Toolkit offers health care stakeholders in rural areas with practical information to support the design, implementation, and evaluation of community paramedicine programs.

California’s Whole Person Care pilot can inform cross-sector initiatives to improve care for Medicaid enrollees with complex health and social needs.

Discharge to medical respite care leads to lower hospital readmission rates among individuals who are frequently admitted to the hospital.

A permanent supportive housing program did not improve most measures related to physical health for individuals experiencing chronic homelessness, but did improve access to and trust in primary care.