An interdisciplinary team approach can improve care coordination and reduce length of hospital stays for older adults with complex health and social needs.

A medical respite program for people experiencing homelessness shows evidence of reduced hospital readmissions and emergency department revisits.

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 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.

This case study highlights an accountable care organization’s home-based primary care program for homebound older adults, with early analysis of outcomes showing reduced acute care utilization.

Complex care management program within Next Generation Accountable Care Organizations reduced cost and utilization for high-risk Medicare beneficiaries.

California’s Whole Person Care pilot can inform cross-sector initiatives to improve care for Medicaid enrollees with complex health and social needs.

A unique cross-sector partnership involving health care, police, and emergency services improved health care utilization in this rural health system pilot.

Impact of social needs navigation program on future utilization of patients with prior high utilization.

This guide for state leaders offers lessons about state-level approaches to complex care.

The VA shares lessons on workforce learning and development.

CareMore’s business model identifies high-risk patients and surrounds them with coordinated services

Home visits can reach patients with complex needs before a higher level of care is needed

Stanford Coordinated Care provides university employees with complex health needs better care at a lower cost