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

Outlines practical steps for implementing flexible supplemental benefit offerings in Medicare Advantage plans.

Indicates that a community-based nurse care management model reduced all-cause mortality for older adults with chronic conditions.

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.

How can a community-based organization demonstrate the two-way financial benefits of partnering with a health plan?

Highlighted innovations adopted by PACE organizations during the pandemic to provide care for older adults with complex needs.

Effective complex care measures vary widely and need to be standardized to better align the field of complex care.

Multisector partnerships that include Area Agencies on Aging may reduce health care use and spending.

Health care systems may need to tailor screening and referral approaches for social needs, as some needs may be less likely to be met by social service organizations.

A telephone-based virtual senior center may help minimize social isolation and loneliness for older adults.

Promising approaches to reduce loneliness for older adults in community and institutional settings.

High-need, high-cost older adult patients detail their health care goals, which may inform provider efforts to effectively engage with and care for these patients and their family caregivers.

Among high-cost Medicare enrollees, those who are seriously ill, frail, and/or had a serious mental illness experience the most potentially preventable spending.

Strategies for reducing the impact of social isolation and loneliness on older adults.

Highlighted lessons from two recent studies to help guide future program and measurement approaches for complex care management interventions.

Ten common attributes for successful care management programs serving high-need, high-cost populations.