Understand emerging evidence and best practices for implementing community engagement interventions to better meet community needs and improve health equity.
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Pairing promotores with clinicians increased in-home visits and reduced acute care use and health care costs for homebound older adults.
Case Example
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
Cost-Effective Care Coordination for People with Dementia at Home
A multidisciplinary care coordination program for older adults with dementia demonstrated a positive return on investment and Medicaid cost savings.
Peer-Reviewed Article
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
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
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
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
Best Programs for Caregiving: Dementia Care Programs for Family Caregivers and Program Providers
National database offers free information on dementia care programs for family caregivers.
Website/Resource Center
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
The Role of Community Health Workers in the Health and Well-Being of Vulnerable Older Adults During the COVID-19 Pandemic
A telephone-based community health worker program offered critical supports for older adults during the COVID-19 pandemic.
Peer-Reviewed Article
A Housing and Health Collaboration: Mount Rubidoux Manor and Inland Empire Health Plan
Embedding a health navigator in a senior housing community improved residents’ sense of physical, mental, and social well-being.
Case Example
Medicare-Medicaid Integrated Care Programs
Curates evidence behind three fully integrated care program models for people who are dually eligible for Medicare and Medicaid, as well as practical strategies that support effective implementation of these programs.
Collection
December 2023
Long-Term Care Equality Index 2023
The Long-Term Care Equality Index advocates for LGBTQ+ inclusive policies and procedures in long-term care settings.
Implementation Tool
Evaluating the Program of All-Inclusive Care for the Elderly (PACE)
Case studies and evidence on how PACE organizations adapted to challenges during the COVID-19 pandemic.
Brief/Report
Improving Nursing Home Care Quality
Curates evidence on improving nursing home care quality and explores practical tools that support effective implementation of care and services that are more person-centered and improve outcomes for nursing home residents.
Collection
November 2023
Lifting the Veil How Networks Form Operate Struggle and Succeed
This report highlights challenges of network-based contracting between health care entities and community-based organizations and shares tips for successful implementation.
Brief/Report
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
Building an LGBTQ+ Inclusive PACE Program: Key Learnings on How the Program of All-Inclusive Care for the Elderly (PACE) Model Addresses the Needs of LGBTQ+ Older Adults
Lessons for developing LGBTQ+ inclusive Program of All-Inclusive Care (PACE) programs for older adults.
Brief/Report
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