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

Person-centered integrated care models designed to respond to the priorities of people dually eligible for Medicare and Medicaid are more likely to increase and sustain enrollment.

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.

Community health worker-led interventions for older adults with complex needs show evidence of improving participant mood and functional outcomes.

Aligned D-SNP enrollment was associated with more efficient service use among some dually eligible beneficiaries.

Case studies and lessons from evidence-based interventions to address social isolation and loneliness in older adults.

A care coordination and palliative care intervention for adults with complex needs was associated with significantly reduced short-term mortality.

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.

Tools, tips, and vignettes for incorporating telehealth into home-based primary care models.

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

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

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.

Home-based primary care programs made rapid care delivery adaptations in response to the COVID-19 pandemic, and this flexibility may support new opportunities to care for older, medically complex patients safely in their homes.

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.

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.