Looks at how the Keystone ACO partnership, serving residents of 41 primarily rural Pennsylvania counties as well as parts of New York, New Jersey and Maryland, is using community health workers to improve the quality and cultural competence of service delivery.

The dialogue on caring for patients with complex needs has moved beyond a recognition that social factors like housing or nutrition have an outsize impact on health to practicalities. Now, health care providers are asking: what can we actually do to help?