Systematic review of programs to improve care for patients with complex needs details evidence base across multiple settings.

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.

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

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

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.

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.

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.

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

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

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.

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.

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.

Home-based intensive care model for Medicaid and dually eligible enrollees with complex needs led to positive health outcomes and reduced acute care spending, particularly for individuals with a behavioral health diagnosis.

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.

Guidance on partnering with community-based organizations to provide services such as meal delivery and transportation for dually eligible individuals.