Recommendations for federal policymakers to improve Medicaid for adults with complex needs and improve long-term services and supports for individuals not eligible for Medicaid.

Using segmentation to address clinical and social needs for Medicaid patients with complex needs and costly utilization can improve the effectiveness of complex care programs.

These resources can help nurses educate and support family caregivers in performing complex medical tasks for their family members at home.

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.

Explored how complex care stakeholders can incorporate a multi-factor approach to measure and demonstrate the value of complex care programs for diverse stakeholders.

This toolkit can support health care organizations in creating the business case for complex care programs.

Segmentation framework with publicly available code files identifies specific and actionable patient cohorts with complex needs.

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.

Contains practical guides, tools, and other resources for developing complex care programs.

Includes patient- and staff-reported measures to help complex care programs better understand the impacts of interventions.

Health care organizations can use population-level data sources about the experiences of people with disabilities to improve care.

Downloadable tools, tip sheets, sample forms, and how-to guides on home-based primary care, with a focus on clinical and operational best practices.

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.

This case study highlights an accountable care organization’s home-based primary care program for homebound older adults, with early analysis of outcomes showing reduced acute care utilization.

Suggests that community-based organizations are responding to Medicaid redesign efforts that prioritize social determinants of health by adopting practices similar to health care organizations.

Offers a practical framework for safety-net health systems to better identify and segment patients with complex needs, and tailor care models to meet their needs.

Provides an overview of home-based medical care models, the patients that they serve, and their robust evidence base.

Describes factors that support health care organizations in transitioning from volume- to value-based payment.

Summarizes different approaches and criteria that can be used to identify patients with complex needs for health system interventions.