Segmentation framework with publicly available code files identifies specific and actionable patient cohorts with complex needs.

Explored how health care organizations can incorporate a segmentation framework into population health management using simple algorithms.

Understanding the values of patients with complex health and social needs can help providers improve care.

A cross-sector partnership to enroll older adults experiencing homelessness in permanent supportive housing led to meaningful reductions in health care costs.

Contains practical guides, tools, and other resources for developing complex care programs.

Use of hospital readmission rates to measure quality may be unfair for some accountable care organizations and safety-net providers, since members with complex medical and social needs are a main driver of these rates.

Includes patient- and staff-reported measures to help complex care programs better understand the impacts of interventions.

Health care organizations can use population-level data sources about the experiences of people with disabilities to improve care.

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.

Patients with dementia are more likely to be discharged to hospice from hospitals that offer palliative care programs.

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.

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