Home-based primary care nurse practitioners improve health outcomes for homebound older adults.

Evaluation of state Medicaid health home model programs details approaches for implementation and outcomes for enrolled members.

Pairing promotores with clinicians increased in-home visits and reduced acute care use and health care costs for homebound older adults.

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.

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.

Evaluation shares health, social, emotional, and financial outcomes resulting from community health worker programs for older adults in Texas.

This toolkit details options for implementing recently introduced Medicare services that address members’ health-related social needs.

Brief provides overview of medication therapy management in Medicaid to support members with multiple chronic conditions.

This study offers a standardized approach for embedding community health workers into primary care, providing a valuable framework for health systems aiming to integrate this workforce.

Medically tailored meals significantly reduced admissions to hospitals and nursing homes for people with complex health and social needs.

Insights from experts, recent research, and state case studies offer actionable recommendations for advancing medically tailored meal initiatives to improve outcomes and reduce costs.

Evaluation of a diabetes-focused medically tailored meals pilot demonstrates improved health outcomes and provides examples of key implementation tools.

Multidisciplinary integrated practice units may have a greater impact on acute care utilization by focusing on patients who have high utilization of emergency departments and are uninsured.

Discharge to medical respite care leads to lower hospital readmission rates among individuals who are frequently admitted to the hospital.

A review of existing literature finds that medical respite care reduces hospital and emergency department visits, increased use of outpatient care, and leads to overall cost savings.

Nurse assessments of discharge readiness for older patients with multiple chronic conditions can help identify patients at high risk for hospital readmission.

Toolkit offers recommendations and examples for screening and interventions that support social connectivity of older adults.

Louisiana improved Medicaid enrollment and health care access for people reentering communities from state prisons.

Interdisciplinary care teams, telehealth, and flexible payment models are included as key recommendations to increase access to home-based primary care in rural communities.

Toolkit offers health care stakeholders interested in working with community members guidance on equitable compensation strategies.