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

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.

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.

Report highlights key strategies for supporting financially sustainable community health worker programs.

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.

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.

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

A primary care-based integrated care team supports patients with type 1 or type 2 diabetes in reducing A1c levels.

Addressing care coordination and medication-related needs within a mobile integrated health care-community paramedicine program leads to a reduction in hospital readmissions.

The reanalysis of a randomized control trial evaluating the effectiveness of a care management program finds increased linkages to ambulatory care.

Toolkit offers health care stakeholders in rural areas with practical information to support the design, implementation, and evaluation of community paramedicine programs.

An interdisciplinary care management program for Medicare patients at increased risk of hospitalization demonstrates a positive return on investment.

A street medicine program increased post-hospitalization follow-up care for unsheltered individuals experiencing homelessness in Los Angeles.

An interdisciplinary home-based primary care program for older adults with limited mobility leads to reductions in health care utilization and costs.

Insights from patient-level encounter histories can support optimizing care coordination team staffing for high-need patients.