This toolkit can support health care organizations in creating the business case for complex care programs.

A Comprehensive Medication Management program that employs a remote clinical pharmacist effectively addresses most drug therapy problems in a complex care population.

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.

CAPABLE, a home-based care program that provides interdisciplinary services for older adults, leads to reductions in disability as well as cost savings.

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.

Randomized controlled trial of a care management intervention shows significant improvement in patient activation and self-rated health and decreased symptoms of depression in patients with complex needs.

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.

A home-based palliative care program using an interdisciplinary care team reduces hospital costs and unnecessary health care utilization for Medicare Advantage beneficiaries.

Home-based palliative care program implemented within an accountable care organization created cost savings through reduced hospital admissions and increased hospice length of stay.

Community health worker-led interventions for older adults with complex needs show evidence of improving participant mood and functional outcomes.

Clearly defining characteristics of complex populations is essential for effective complex care intervention design.

Home-based program provided by a community health and social worker reduces acute care use and improves care for older adults with complex health and social needs.

A care coordination and palliative care intervention for adults with complex needs was associated with significantly reduced short-term mortality.

Medicare Advantage plans report different barriers to partnering with community-based organizations, but there are strategies to develop effective partnerships.

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.

Tools, tips, and vignettes for incorporating telehealth into home-based primary care models.