The Point of Reentry and Transition program connects adults leaving NYC's Rikers Island jail to trauma-informed, patient-centered primary care and other essential health and social services.

Shares insights from a panel of national complex care experts who discussed the latest research on addressing social needs in health care and how to translate evidence into practice at the local, state, and national levels.

The Better Care Playbook spoke with Elder Angela Overton, Senior Advisor and Director of Faith Community Partnerships at the Coalition to Transform Advanced Care, to discuss the Louisville Community Model of Care Project.

Highlights recent findings on the effectiveness of medically tailored meals and the impacts these programs have on hospitalizations, patient costs, and clinical outcomes, and also outlines implementation considerations.

State policymakers can use this resource roundup to understand emerging best practices for member engagement, with a focus on adults with complex needs.

Explores evidence on the effectiveness of medical respite care and the impacts this approach has on patient outcomes, hospital visits, and costs.

Sharon Bean and Ernest Egu, MD, discuss their corrections-health partnership that has reduced the risk of overdose among people leaving jail by offering medication for addiction treatment.

Kathryn Jantz from HealthBegins, discusses how health care organizations and community-based organizations can use an return on investment calculator to support partnerships that address patients’ health-related social needs.

Profiles the Program to Encourage Active, Rewarding Lives (PEARLS), an evidence-based treatment program for older adults experiencing late-life depression, and how the program is decreasing access barriers to behavioral health services for older adults.

Laura Gottlieb, founding co-director of the Social Interventions Research and Evaluation Network, discusses emerging evidence on social care interventions and identifies pathways through which social care programs likely impact health.

Connecticut Community of Addiction Recovery helps people with substance use disorder achieve and sustain recovery through community-based non-clinical social support programs, volunteer opportunities, and referrals to detox, treatment, housing, employment, among other resources.

Explores how the Fountain House implemented the clubhouse model, a unique approach that empowers people with serious mental illness to form meaningful relationships, build resilience, improve self-management of their mental health, and pursue employment, education, and housing.

This essay from Lawrence Lincoln, a former unhoused person in California, documents his journey of recovery and subsequent work with a care community.

Profiles Central City Concern, an FQHC in Portland, Oregon, that is providing services for people experiencing homelessness with substance use disorder — including primary care, behavioral health treatment, housing, and other supports.

Aditi Vasan, MD, MSHP, a health services researcher, delved into how community health workers can be helpful to patients with complex health and social needs, based on current evidence.

Jennifer Babcock of the Association of Community Affiliated Plans discusses state efforts to promote sustainable financing for Medicaid health plans to address health-related social needs and how these efforts can result in better outcomes for people with complex care needs.

Highlights a national network of primary care clinics that offer comprehensive health care and social supports to people released from incarceration.

Features a conversation with Emilia De Marchis, MD, MAS, assistant professor at UCSF’s Department of Family and Community Medicine, who explores the findings from a report on the state of social needs screening in health care settings.

This blog post examines what factors are associated with successful partnerships between AAAs and health care entities.

Features a conversation about Illumination Foundation's approach to data analytics and how it can inform other organizations seeking to improve care for people experiencing homelessness.