Content Types

Displaying 1 - 20 of 58

The People Say

Website offers a qualitative database of personal narratives to support providers and policymakers in designing policies that better reflect the lived experience, needs, and priorities of older adults.

Implementation Tool

August 2025

Bridges to Elders: A Program to Improve Outcomes for Older Women Experiencing Homelessness

Program led by a nurse practitioner and community health worker improved housing stability, access to primary care, and chronic disease management among older women experiencing homelessness.

Peer-Reviewed Article

January 2025

Building Healthy Communities: Community Health Worker Impact on Older Adults in Texas

Evaluation shares health, social, emotional, and financial outcomes resulting from community health worker programs for older adults in Texas.

Brief/Report

August 2024

Socioeconomic Factors Associated with Uptake and Satisfaction with a Post-Hospitalization Meals Benefit in Medicare Advantage

A post-hospitalization supplemental home-delivered meals benefit saw significant uptake and high satisfaction among Medicare Advantage members with greater financial or food insecurity.

Peer-Reviewed Article

March 2024

Understanding the Medicare Physician Fee Schedule Billing Codes For: Community Health Integration, Principal Illness Navigation, and Principal Illness Navigation-Peer Support Services

This toolkit details options for implementing recently introduced Medicare services that address members’ health-related social needs.

Implementation Tool

March 2024

Bridging the Home-Based Primary Care Gap in Rural Areas

Interdisciplinary care teams, telehealth, and flexible payment models are included as key recommendations to increase access to home-based primary care in rural communities.

Brief/Report

February 2024

Association Between ICD-10 Codes for Social Needs and Subsequent Emergency and Inpatient Use

An association between Z code assignment and increased emergency and inpatient health care utilization presents opportunities for targeted interventions that address patients' social needs.

Peer-Reviewed Article

November 2023

Addressing Healthcare Utilization and Costs for Older Adults with Limited Mobility Through a Multidisciplinary Home-Based Primary Care Program

An interdisciplinary home-based primary care program for older adults with limited mobility leads to reductions in health care utilization and costs.

Peer-Reviewed Article

August 2023

Scaling Primary Care Social Needs Screening and Referrals in New York City’s Safety-Net Health System

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.

Case Example

June 2023

A Pilot Randomized Controlled Trial of CAPABLE in Permanent Supportive Housing for Formerly Homeless Adults

Randomized controlled trial of a person-centered housing intervention for older adults shows improved health outcomes for formerly homeless adults living in permanent supportive housing.

Peer-Reviewed Article

April 2023

Community Health Worker Programs in Primary Care

Curates recent evidence behind community health worker programs that support people with complex health and social needs, as well as practical strategies to support effective implementation of these programs.

Collection

April 2023

Lifting the Veil How Networks Form Operate Struggle and Succeed

This report highlights challenges of network-based contracting between health care entities and community-based organizations and shares tips for successful implementation.

Brief/Report

April 2023

Community Health Worker Model Best Practice Toolkit for Designing, Implementing and Showing Impact

Toolkit provides best practices and practical tools for designing, implementing, and evaluating the impact of community health workers.

Implementation Tool

March 2023

The Role of Community Health Workers in the Health and Well-Being of Vulnerable Older Adults During the COVID-19 Pandemic

A telephone-based community health worker program offered critical supports for older adults during the COVID-19 pandemic.

Peer-Reviewed Article

February 2023

Association of National Expansion of Insurance Coverage of Medically Tailored Meals with Estimated Hospitalizations and Health Care Expenditures in the US

Simulation model estimates that national implementation of medically tailored meal programs for specific populations would achieve over $13.6 billion in cost savings per year.

Peer-Reviewed Article

October 2022

Guide to Evidence for Health-Related Social Needs Interventions: 2022 Update

Summarizes evidence on costs of health-related social needs interventions and their impact on utilization and cost of care to inform ROI Calculator users.

Implementation Tool

September 2022

Integrating Spiritual Care in Population Health and Care Management: Two Case Examples

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.

Case Example

September 2022

Defining Case Management Success: A Qualitative Study of Case Manager Perspectives from a Large-Scale Health and Social Needs Support Program

Case managers noted establishing trust, fostering mindset changes, and increasing stability and independence can be measures of success when working with people with complex needs.

Peer-Reviewed Article

June 2022

State of the Science on Social Screening in Healthcare Settings

Summarizes research on the prevalence of social screening in health care settings, validity of social screening tools, and patient and provider perspectives on social screening.

Brief/Report

June 2022

Applying the ROI Calculator for Partnerships to Address Social Determinants of Health

Described how health care organizations and community-based organizations can use the ROI Calculator to explore and plan financial arrangements to fund social services for people with complex needs.

Webinar

May 2022

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The People Say

Bridges to Elders: A Program to Improve Outcomes for Older Women Experiencing Homelessness

Building Healthy Communities: Community Health Worker Impact on Older Adults in Texas

Socioeconomic Factors Associated with Uptake and Satisfaction with a Post-Hospitalization Meals Benefit in Medicare Advantage

Understanding the Medicare Physician Fee Schedule Billing Codes For: Community Health Integration, Principal Illness Navigation, and Principal Illness Navigation-Peer Support Services

Bridging the Home-Based Primary Care Gap in Rural Areas

Association Between ICD-10 Codes for Social Needs and Subsequent Emergency and Inpatient Use

Addressing Healthcare Utilization and Costs for Older Adults with Limited Mobility Through a Multidisciplinary Home-Based Primary Care Program

Scaling Primary Care Social Needs Screening and Referrals in New York City’s Safety-Net Health System

A Pilot Randomized Controlled Trial of CAPABLE in Permanent Supportive Housing for Formerly Homeless Adults

Community Health Worker Programs in Primary Care

Lifting the Veil How Networks Form Operate Struggle and Succeed

Community Health Worker Model Best Practice Toolkit for Designing, Implementing and Showing Impact

The Role of Community Health Workers in the Health and Well-Being of Vulnerable Older Adults During the COVID-19 Pandemic

Association of National Expansion of Insurance Coverage of Medically Tailored Meals with Estimated Hospitalizations and Health Care Expenditures in the US

Guide to Evidence for Health-Related Social Needs Interventions: 2022 Update

Integrating Spiritual Care in Population Health and Care Management: Two Case Examples

Defining Case Management Success: A Qualitative Study of Case Manager Perspectives from a Large-Scale Health and Social Needs Support Program

State of the Science on Social Screening in Healthcare Settings

Applying the ROI Calculator for Partnerships to Address Social Determinants of Health