Community-based care management programs for patients with complex health and social needs have the potential to reduce hospitalizations and inpatient costs.

Health insurers can implement strategies to address bias in machine learning and predictive modeling used in care management to help reduce health inequities and racial disparities.

Over 14 years, individuals experiencing chronic homelessness enrolled in a permanent supportive housing program had low housing retention and high mortality.

Describes the core elements and evidence base behind a home- and community-based palliative care model that was designed by stakeholders to support the health needs of people with serious illness.

This guide describes key strategies for health plans, accountable care organizations, and health systems to improve care for people with serious illness.

Home-based palliative care providers explore key facilitators and barriers to effectively delivering care within a value-based payment environment.

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.

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.

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

Looked at the provider and payer relationship and discussed how successful partnerships between these two stakeholders can create sustainable and efficacious home and community based palliative care programs.

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

Synthesis of studies on effective home-based palliative care emphasizes essential elements for creating a quality program.

This toolkit shares business strategies, sample protocols, and best practice clinical tools for health care providers interested in developing a home-based palliative care program.

A practical guide for payers to create a home-based palliative care program centered upon a value-based case example from a payer’s perspective.

A home-based palliative care program in a full-risk financial arrangement showed consistent cost savings and lower hospital utilization across a 10-year period.

A home-based palliative care program using an interdisciplinary care team reduces hospital costs and unnecessary health care utilization for Medicare Advantage beneficiaries.

A community-based palliative care program reduced medical costs, intensive care unit (ICU) admissions, hospital admissions, and days spent in the hospital for Medicare Advantage members with serious illness.

Care model that integrates home-based primary care and palliative care for patients with serious illness reports reduced health care utilization and improved patient care experience.

Home-based palliative care program implemented within an accountable care organization created cost savings through reduced hospital admissions and increased hospice length of stay.