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.

Highlights the Care Transitions Intervention (CTI), an evidence-based, short-term model that helps prevent unnecessary hospital readmissions and emergency department visits and reduce unnecessary spending.

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

Describes how provider organizations in Rhode Island employ multidisciplinary teams, including community health workers and behavioral health clinicians, to collaborate with primary care practices in providing whole-person care.

Profiles Support and Services at Home, a model that is empowering older adults and people with disabilities to remain at home via in-home supports and services.

Profiles Yakima Neighborhood Health Services, a health center in Washington State, that launched a medical respite care program in 2010 after a focus group of patients experiencing homelessness expressed the need for a place to stay when they were sick.

Profiles the ONE Health program at Regional One Health in Memphis, Tennessee, which focuses on uninsured individuals and has achieved reductions in emergency department use and inpatient care, resulting in savings to reinvest in care improvements.

Profiles the Rush Caregiver Intervention at Rush University Medical Center, that is working to transform how the health care system interacts with family caregivers, while providing programs and services that support caregivers and their family members.

Profiles Landmark Health, company to bring comprehensive care to the homes of older adult patients with multiple chronic conditions.

Profiles CAPABLE, is a participant-driven model that improves function by addressing the home environment and using the strengths of the older adults themselves.

Details a partnership between Commonwealth Care Alliance, a non-profit community-based payer and provider serving people with significant needs, and Hearth, a non-profit community-based organization focused on ending elder homelessness, to provide permanent supportive housing for eligible individuals.

Features Housecall Providers, a non-profit medical provider serving Portland, Oregon, offering comprehensive home- and community-based programs that incorporate palliative care services and provide patient-driven, high-touch support wherever patients call home.

Highlights Cleveland Clinic's Paramedic Telehealth Program that provides urgent and transitional care for home-based primary care patients.

Details the elements of Rush@Home’s care model and shares the impact and insights from implementing this home-based primary care program.