Using community health workers can reduce hospitalizations in high-risk patients.

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

Social workers on rural primary care teams may help decrease high-risk veterans’ acute care use.

Complex care management program for high-need, high-cost Medicaid patients demonstrates substantially lower spending and inpatient utilization.

Providing virtual case mentoring to outpatient care teams may reduce unnecessary hospital and emergency department visits for high-need, high-cost patients.

Connecting complex care teams with specialists through videoconferencing can increase their effectiveness in caring for high-need high-cost patients.

Describes how health care providers and their correctional agency partners can design medications for addiction treatment programs for people with opioid use disorder in jails and prisons.

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

A multidisciplinary care coordination program for older adults with dementia demonstrated a positive return on investment and Medicaid cost savings.

An interdisciplinary, hospital-based addiction medicine consultation team improved substance use disorder treatment engagement after hospitalization.

The benefits of a transitional care program.

How staff composition affects care delivery for older adults.

Nurse practitioners and physician assistants are associated with lower costs.

Staff time effort in complex care coordination programs is highly variable depending on patients’ health and social needs.

Details the main elements of a hospital-based addiction care consultation team.

Fostering a culture of caring for veterans takes interdisciplinary teams focused on comprehensive, trusting and reliable relationships through open and frequent communication and ongoing education.

A hospitalist model for complex care.

The case conference approach to caring for complex patients.

This resource describes the benefits of community health workers for people with multiple chronic conditions.

Home visits can reach patients with complex needs before a higher level of care is needed