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.

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.

Demonstrates that intensive outpatient care programs show promise in reducing utilization and costs and improving patient outcomes for high-need, high-cost populations.

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.

An initiative to distribute tablets to high-need veterans successfully reached individuals with barriers to health care access.

Integrated health care systems can better support high-risk patients by embedding high-risk patient care within general primary care and mental health care.

Tips on integrating community health workers into quality improvement teams to address patients’ social needs.

Community health worker programs can offset program costs through reduced utilization.

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?

Accountable care organizations (ACOs) and tailored care coordination strategies may improve preventable hospitalizations and reduce racial disparities among patients with coexisting physical and mental health conditions.

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

Provider-based model identifies patients at highest risk for complications from COVID-19.