Describes how a health system can adapt workflow, roles and responsibilities, and communication to engage family caregivers in care transitions and comply with CARE Act requirements.

Systematic review finds mixed results for health information technology in enhancing coordinated care and improving health outcomes for people with multiple chronic conditions.

Longer participation in a patient-centered medical home is associated with better mental health care for people enrolled in Medicaid with major depressive disorder and multiple chronic conditions.

In nursing homes, replacing on-call physician services during off-hours with direct contact via telemedicine may reduce Medicare spending through fewer avoidable hospitalizations.

Telehealth interventions had similar outcomes to in-person care for different services and populations, but did not consistently impact utilization such as physician or emergency department visits.

Telehealth may address barriers to accessing substance use disorder interventions and is a promising alternative to in-person treatment.

Care team models with more nurse practitioners and physician assistants than physicians are associated with increased primary care and geriatrics services provision and reduced labor costs.

A Comprehensive Medication Management program that employs a remote clinical pharmacist effectively addresses most drug therapy problems in a complex care population.

For people with disabilities, familiarity with their care teams and care plans, and increased access to long-term services and supports can improve their perceptions of quality of life and health care.

Understanding the values of patients with complex health and social needs can help providers improve care.

Black Medicaid enrollees who spent more days in the emergency department or county jail were less likely than white enrollees to receive medications for opioid use disorder.

CAPABLE, a home-based care program that provides interdisciplinary services for older adults, leads to reductions in disability as well as cost savings.

Advance care planning more than one month prior to death is associated with decreased acute care utilization at the end of life and in-hospital death for people with serious illness.

A cross-sector partnership to enroll older adults experiencing homelessness in permanent supportive housing led to meaningful reductions in health care costs.

Analysis of 310 health systems showed gaps in opioid receipt between Black and white patients, especially on dosage, which may be related to racial bias among clinicians.

Randomized controlled trial of a care management intervention shows significant improvement in patient activation and self-rated health and decreased symptoms of depression in patients with complex needs.

A Medicaid health home care management program led to improved diabetes care, benefitting people with co-occurring substance use disorders and diabetes.

Profile of a geriatric emergency department model for older adults with complex needs includes sample policies and workflows as well as recommendations to support effective implementation.

Use of hospital readmission rates to measure quality may be unfair for some accountable care organizations and safety-net providers, since members with complex medical and social needs are a main driver of these rates.

Synthesis of studies on effective home-based palliative care emphasizes essential elements for creating a quality program.