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.

Primary care medical home improved use of preventive services, chronic illness care, care experience, psychotic symptoms, and mental health-related quality of life for people with serious mental illness.

Housing needs assessment tool can help providers who work with people leaving incarceration to better understand their housing needs and risk of homelessness.

Hospital at home services show similar or better outcomes when compared with traditional inpatient care for Medicaid enrollees.

Peer recovery coaching intervention for hospitalized people with substance use disorder led to mixed acute care utilization outcomes.

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.

A hospital successfully integrated a harm reduction services intervention for patients whose substance use goals did not include abstinence.

Pharmacy co-dispensing of naloxone with opioid prescriptions improved naloxone receipt and overdose prevention knowledge without encouraging risk behaviors.

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

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

Care management interventions demonstrated improvements in mental health, quality of life, and patient satisfaction as well as reduced psychiatric inpatient days for people with serious mental illness.

A hospital-based program showed that peer recovery coaching can be seamlessly integrated into the workflow of busy emergency departments to address the longer-term needs of people with substance use disorders.

A nursing home telehealth program resulted in reduced emergency department visits and health care expenditures for Medicare beneficiaries.

Systematic review finds that gender-response programs are associated with reductions in reincarceration for women with substance use disorder leaving jail or prison.

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.

A participatory design approach created a nurse-driven screening process to better identify and treat people with opioid use disorder in the emergency department.

Inpatient addiction medicine consultation services reduced 90-day mortality for patients with substance use disorder after a hospital discharge, but showed mixed results on acute care utilization.