A complex care transitions pilot designed through a stakeholder-driven process led to decreased hospital utilization and costs.

Medicare patients with the top five percent in preventable utilization account for almost half of all avoidable Medicare costs.

Tips on integrating community health workers into quality improvement teams to address patients’ social needs.

The value of community health workers in advancing health equity.

Demonstrating return-on-investment to advance effective business relationships between community-based organizations and health care partners.

How can a community-based organization demonstrate the two-way financial benefits of partnering with a health plan?

Effective complex care measures vary widely and need to be standardized to better align the field of complex care.

Health care systems may need to tailor screening and referral approaches for social needs, as some needs may be less likely to be met by social service organizations.

Adults with complex, high-cost health care needs are more likely to have experienced social adversity in childhood and adulthood.

Highlighted lessons from two recent studies to help guide future program and measurement approaches for complex care management interventions.

Integrating medical, behavioral health, and social services data tells a fuller story of frequent emergency department users’ service utilization and may identify candidates for care coordination.

Ten common attributes for successful care management programs serving high-need, high-cost populations.

Complex care management program for high-need, high-cost Medicaid patients demonstrates substantially lower spending and inpatient utilization.

Providing virtual case mentoring to outpatient care teams may reduce unnecessary hospital and emergency department visits for high-need, high-cost patients.

Connecting complex care teams with specialists through videoconferencing can increase their effectiveness in caring for high-need high-cost patients.

Randomized controlled trial of a care management intervention offers important lessons for the field of complex care.

A unique cross-sector partnership involving health care, police, and emergency services improved health care utilization in this rural health system pilot.

Recommendations for integrating social and health care to improve the nation’s health.

Impact of social needs navigation program on future utilization of patients with prior high utilization.

A standardized tool to assess where along a continuum a program lies with regard to components of integration.