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.

Tailoring palliative care interventions for people who are members of ethnic and racial minority groups may support increased access to palliative care and end of life services.

Presents a framework and tools to help health care organizations and communities design a community-based palliative care program to meet patient needs in rural settings.

This case study analyzes a successful example of a medical group partnering with a home health agency to provide community-based palliative care for high-risk members of their accountable care organization.

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.

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

A home-based primary care program led to reduced medical costs for frail elderly patients, primarily due to lower spending at end-of-life.

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.

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.

Creating clinically meaningful profiles of patients with medically complex needs can support the delivery of more tailored interventions.

The 4Ms approach developed for the Age-Friendly Health System model — what matters, medication, mentation, mobility — has a robust evidence base for providing quality care to older adults.

Implementing a predictive model in acute settings can more reliably identify patients with high mortality risk, which can assist providers in prioritizing advance care planning.

Evaluates the evidence on interventions for people living with dementia, their care partners, and caregivers to help identify what interventions are ready for broad implementation.

Step-by-step guide with robust tools for health systems to apply the 4Ms framework to deliver age-friendly, evidence-based care for older adults.

Clinical tools, training resources, and case studies of evidence-based care models that support people living with dementia and their caregivers.

Patients with dementia are more likely to be discharged to hospice from hospitals that offer palliative care programs.

Medication management interventions that support caregivers of people with dementia at care transitions can help reduce readmissions, caregiver burden, and use of high-risk medication.