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.

Dawn Wiest, PhD, Director for Research and Evaluation at the Camden Coalition, discusses findings from an analysis of Camden Coalition’s care management program, which found that the program led to a significant reduction in hospital readmissions among engaged program participants.

Carl Rush, policy advisor on community health worker (CHW) initiatives in more than 20 states, discusses the CHW program policy landscape and what policymakers can do to advance these efforts for people with complex needs.

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.

Arianna Campbell, director and co-principal investigator for CA Bridge, discusses how the bridge model came about and how it works.

The Playbook’s summer reading list offers a selection of blog posts and evidence summaries that showcase innovative strategies for improving care for people with complex needs.

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.

Explores the evidence behind harm reduction strategies and shares practical steps for adopting this approach in health care settings.

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.

Explores how to implement quality addiction care in general health care settings -- including primary, inpatient, and emergency care.

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.

The Playbook spoke to two individuals who helped develop the Patient-Centered Complex Care Research Agenda to learn more about how involving people with lived experience in research can help strengthen the complex care evidence base.

Reviews findings from a Playbook Collection on innovative addiction care models, including emerging evidence for these approaches and considerations for implementation.

Features commentary from Ben Miller, PsyD, past president at Well Being Trust, on the value of peer supports in mental health or addiction recovery.

Learn about program design considerations for an intensive care management program with promising evidence in this conversation with program leaders at Mass General Brigham and Commonwealth Care Alliance.

Features a conversation with Danetta Sloan, PhD, MSW, MA, assistant scientist at Johns Hopkins Bloomberg School of Public Health, to learn about the MIND at Home program and how dementia care coordination programs can better support Black caregivers and their families.

This Tradeoffs podcast episode explores ways to make palliative care more equitable and shares a caregiver's journey navigating a serious illness.

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.