Displaying 1 - 20 of 121

Home-Based Primary Care Visits by Nurse Practitioners

Home-based primary care nurse practitioners improve health outcomes for homebound older adults.

Peer-Reviewed Article

June 2023

Clinicians and Promotores Teaming to Provide In-Home Primary Care to Frail Older Adults

Pairing promotores with clinicians increased in-home visits and reduced acute care use and health care costs for homebound older adults.

Case Example

July 2023

Bridges to Elders: A Program to Improve Outcomes for Older Women Experiencing Homelessness

Program led by a nurse practitioner and community health worker improved housing stability, access to primary care, and chronic disease management among older women experiencing homelessness.

Peer-Reviewed Article

January 2025

Diabetes Management Among Underserved Older Adults Through Telemedicine and Community Health Workers

Research review finds that incorporating community health workers into primary care reduced A1c levels and improved self-management and satisfaction among older adults with diabetes.

Peer-Reviewed Article

January 2022

Building Healthy Communities: Community Health Worker Impact on Older Adults in Texas

Evaluation shares health, social, emotional, and financial outcomes resulting from community health worker programs for older adults in Texas.

Brief/Report

August 2024

Understanding the Medicare Physician Fee Schedule Billing Codes For: Community Health Integration, Principal Illness Navigation, and Principal Illness Navigation-Peer Support Services

This toolkit details options for implementing recently introduced Medicare services that address members’ health-related social needs.

Implementation Tool

March 2024

Effect of Discharge Readiness on 30-Day Readmissions Among Older Adults Living with Chronic Conditions

Nurse assessments of discharge readiness for older patients with multiple chronic conditions can help identify patients at high risk for hospital readmission.

Peer-Reviewed Article

January 2024

Addressing Social Isolation and Loneliness Among Older Dually Eligible Individuals

Toolkit offers recommendations and examples for screening and interventions that support social connectivity of older adults.

Implementation Tool

November 2022

Bridging the Home-Based Primary Care Gap in Rural Areas

Interdisciplinary care teams, telehealth, and flexible payment models are included as key recommendations to increase access to home-based primary care in rural communities.

Brief/Report

February 2024

Telehealth Outcomes and Impact on Care Delivery: A Review of Evidence

Report summarizes the evidence on outcomes for patients participating in various telehealth delivered services, including different modalities, such as telephone and video.

Brief/Report

November 2023

Rural Community Paramedicine Toolkit

Toolkit offers health care stakeholders in rural areas with practical information to support the design, implementation, and evaluation of community paramedicine programs.

Implementation Tool

June 2020

A Clinical Pathway to Well-Being: Putting Patient Priorities at the Center of Care

A care management model designed to center patients’ health priorities shows promising results.

Peer-Reviewed Article

October 2023

Addressing Healthcare Utilization and Costs for Older Adults with Limited Mobility Through a Multidisciplinary Home-Based Primary Care Program

An interdisciplinary home-based primary care program for older adults with limited mobility leads to reductions in health care utilization and costs.

Peer-Reviewed Article

August 2023

Community-Based Organization Services Evidence Bank

Curated collection of research studies highlights the efficacy of services provided by community-based organizations, with a focus on outcomes relevant to health care partners.

Website/Resource Center

August 2023

A Pilot Randomized Controlled Trial of CAPABLE in Permanent Supportive Housing for Formerly Homeless Adults

Randomized controlled trial of a person-centered housing intervention for older adults shows improved health outcomes for formerly homeless adults living in permanent supportive housing.

Peer-Reviewed Article

April 2023

Community Health Worker Programs in Primary Care

Curates recent evidence behind community health worker programs that support people with complex health and social needs, as well as practical strategies to support effective implementation of these programs.

Collection

April 2023

Community Health Worker Model Best Practice Toolkit for Designing, Implementing and Showing Impact

Toolkit provides best practices and practical tools for designing, implementing, and evaluating the impact of community health workers.

Implementation Tool

March 2023

Partnering with Community Health Workers/Promotores to Adapt, Deliver, and Evaluate a Home-Based Collaborative Care Model to Improve Access to Quality Depression Care for Older Latino Adults

A home-based collaborative care model using community health workers shows reductions in depression and increased connection to services for older adults.

Peer-Reviewed Article

February 2023

Details of Developing and Implementing an Intensive Interdisciplinary Care Program for High Need, High Cost Patients

Case study of interdisciplinary primary care program for high-risk patients based at an academic health system offers lessons on program design and implementation.

Case Example

June 2021

Integrating Spiritual Care in Population Health and Care Management: Two Case Examples

Including spiritual care within care management programs in outpatient, managed care, and population health settings can enhance patient care and support the effectiveness of the interdisciplinary care team.

Case Example

September 2022

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Home-Based Primary Care Visits by Nurse Practitioners

Clinicians and Promotores Teaming to Provide In-Home Primary Care to Frail Older Adults

Bridges to Elders: A Program to Improve Outcomes for Older Women Experiencing Homelessness

Diabetes Management Among Underserved Older Adults Through Telemedicine and Community Health Workers

Building Healthy Communities: Community Health Worker Impact on Older Adults in Texas

Understanding the Medicare Physician Fee Schedule Billing Codes For: Community Health Integration, Principal Illness Navigation, and Principal Illness Navigation-Peer Support Services

Effect of Discharge Readiness on 30-Day Readmissions Among Older Adults Living with Chronic Conditions

Addressing Social Isolation and Loneliness Among Older Dually Eligible Individuals

Bridging the Home-Based Primary Care Gap in Rural Areas

Telehealth Outcomes and Impact on Care Delivery: A Review of Evidence

Rural Community Paramedicine Toolkit

A Clinical Pathway to Well-Being: Putting Patient Priorities at the Center of Care

Addressing Healthcare Utilization and Costs for Older Adults with Limited Mobility Through a Multidisciplinary Home-Based Primary Care Program

Community-Based Organization Services Evidence Bank

A Pilot Randomized Controlled Trial of CAPABLE in Permanent Supportive Housing for Formerly Homeless Adults

Community Health Worker Programs in Primary Care

Community Health Worker Model Best Practice Toolkit for Designing, Implementing and Showing Impact

Partnering with Community Health Workers/Promotores to Adapt, Deliver, and Evaluate a Home-Based Collaborative Care Model to Improve Access to Quality Depression Care for Older Latino Adults

Details of Developing and Implementing an Intensive Interdisciplinary Care Program for High Need, High Cost Patients

Integrating Spiritual Care in Population Health and Care Management: Two Case Examples