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

Medicare Advantage plans should identify patients based on medical and social risk factors, not just medical diagnoses.

Accountable Care Organization leaders explore approaches to segmenting high-need, high-cost populations.

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.

Multiple factors, including geographic variation in available resources, may limit take-up among MA plans of new benefit flexibilities.

A model to improve health and quality of life for rural seniors.

How to implement the new Medicare benefits.

How home visits are used by ACOs to improve care, lower costs.

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

This toolkit details the benefits of home-based primary care to help providers demonstrate the need for these programs.

Predictive modeling to reduce ED utilization.

The psychological benefits of case management.

How ACOs can improve care coordination.

Assessing post-discharge needs.

Challenges and opportunities for older adults with multiple chronic conditions.

Includes national survey data on family caregivers and their experiences in managing complex medical and nursing tasks for their family members at home, as well as recommendations to improve the supports for family caregivers.

Four care management models for ACOs.

A tool for assessing readiness for value-based partnerships.