Medicare Advantage plans report different barriers to partnering with community-based organizations, but there are strategies to develop effective partnerships.

People with multiple chronic conditions and disabilities enrolled in home-based primary care experienced persistent reduced acute care utilization.

A home-based primary care program led to reduced medical costs for frail elderly patients, primarily due to lower spending at end-of-life.

Fostering a culture of caring for veterans takes interdisciplinary teams focused on comprehensive, trusting and reliable relationships through open and frequent communication and ongoing education.

Systematic review demonstrates the potential of home-based primary care interventions for improving heath, cost, and patient experience outcomes for adults with multiple chronic conditions and serious disabilities.

Home-based primary care program reduced hospitalizations for older adults with diabetes, especially those with higher levels of medical complexity.

Home-based primary care integrated with long-term services and supports in the community can delay long-term institutionalization in frail older adults without increased costs for home- and community-based services.

Strategies for home-based primary care practices to improve efficiency and support program growth based on qualitative research.

The Department of Veterans Affairs home-based primary care program reduced total costs of care for VA and Medicare and earned high satisfaction ratings from patients and their caregivers.

Primary care and alternative payment models that reduce emergency department use and increase access to care for high-need populations share core components for success.

Personalized patient navigation supports for people with comorbid substance use disorders reduced rates of hospital readmissions and emergency department use.

Disparities in transitional care training for caregivers of older adults based on race or financial status demonstrate need for changes in discharge processes and strategies to address bias.

An intervention supporting caregivers of adults with chronic medical and functional needs can generate cost savings and improve outcomes for Medicare Advantage enrollees and their caregivers.

Creating clinically meaningful profiles of patients with medically complex needs can support the delivery of more tailored interventions.

Use of machine learning clustering algorithms revealed 30 distinct subgroups of patients among high-risk veterans, indicating a need for tailored approaches to health care.

The 4Ms approach developed for the Age-Friendly Health System model — what matters, medication, mentation, mobility — has a robust evidence base for providing quality care to older adults.

Implementing a predictive model in acute settings can more reliably identify patients with high mortality risk, which can assist providers in prioritizing advance care planning.

An affordable housing program in Baltimore generates between $1.30-$1.92 of “social return” in the community for every dollar invested annually.

Home-based primary care programs enable care teams to gain insights on a variety of social factors that impact older adults’ health, which allows them to better tailor care to meet patient needs.

Many physicians report low confidence in caring for patients with disability and negative perceptions about quality of life with a disability, which may reflect biased views that potentially contribute to persistent health disparities.