Offers practical recommendations to improve telemedicine interventions to be more equitable for diverse populations, particularly those with low incomes.

Describes electronic health record system functionality that automatically identifies patients likely to need technical assistance prior to telehealth visits.

Discusses the benefits and challenges of tele-social care and offers practical tips for providers administering telehealth services for social care activities.

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.

Explored how health care organizations can incorporate a segmentation framework into population health management using simple algorithms.

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

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.

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

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.

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.