Primary care and alternative payment models that reduce emergency department use and increase access to care for high-need populations share core components for success.

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

Use of machine learning clustering algorithms revealed 30 distinct subgroups of patients among high-risk veterans, indicating a need for tailored approaches to health care.

An affordable housing program in Baltimore generates between $1.30-$1.92 of “social return” in the community for every dollar invested annually.

Suggests that community-based organizations are responding to Medicaid redesign efforts that prioritize social determinants of health by adopting practices similar to health care organizations.

Offers a practical framework for safety-net health systems to better identify and segment patients with complex needs, and tailor care models to meet their needs.

Provides an overview of home-based medical care models, the patients that they serve, and their robust evidence base.

Describes factors that support health care organizations in transitioning from volume- to value-based payment.

Summarizes different approaches and criteria that can be used to identify patients with complex needs for health system interventions.

Contains strategies, tips, and case studies to assist health care stakeholders in building meaningful, person-centered engagement in their organizations.

Examines promising strategies to meet the needs of dually eligible individuals with serious mental illness, with an emphasis on opportunities to innovate with flexible spending within a capitated payment model.

Details how dually enrolled beneficiaries have significantly higher levels of comorbidities and higher costs of care than their non-dually enrolled counterparts.

Summarizes evidence on how integrated care models affect health and cost outcomes for dually eligible beneficiaries.

Describes core competencies that convey the essential knowledge, skills, and attitudes of complex care practitioners and teams to improve care for people with complex needs.

Presents tools and tips frontline care management staff to address high-risk patients’ unmet social health needs during the COVID-19 pandemic.

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.