Recommendations for building a stronger, more coordinated, and patient-centered complex care evidence base.

Patients with complex needs were more satisfied with in-home urgent care delivered by community paramedics than with emergency department urgent care.

Describes a primary care organization’s approach to using machine learning versus provider judgement to assign primary care visit frequency and better identify future risk of hospitalization and medical cost.

Analytical approach for randomized controlled trials may be valuable for understanding the impact of complex care interventions and the subpopulations that may benefit from them.

A short-term emergency department navigator program helped address acute care utilization for individuals with low baseline utilization through primary care follow up appointments and assistance with social needs.

Medicaid enrollees in a community health worker program had fewer emergency department visits and more outpatient ambulatory care use than beneficiaries who received usual care.

A "virtual-first" transitional care program with an interdisciplinary care team can support reduced readmissions.

Community-based care management programs for patients with complex health and social needs have the potential to reduce hospitalizations and inpatient costs.

Interdisciplinary primary care models can help reduce acute care use for individuals with histories of high emergency department use, homelessness, or substance use disorder.

Systematic review finds that medical respite programs reduce acute care utilization outcomes for people experiencing homelessness.

A permanent supportive housing program did not improve most measures related to physical health for individuals experiencing chronic homelessness, but did improve access to and trust in primary care.

Resources to help organizations plan and implement medical respite care programs, including program development guides, case examples, and implementation tools.

Literature review examines the roles and contributions of community health workers in improving dementia care.

Shared practical implementation considerations that can support health plans and provider groups in developing community-based models of care that use the strengths of social workers and community health workers.

Patients and community health workers (CHWs) share perspectives on the impact of CHW services provided within a primary care setting to address barriers to equitable care.

Systematic review of programs to improve care for patients with complex needs details evidence base across multiple settings.

Including caregivers in the discharge planning process reduces the risk of hospital readmission for older adults.

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

Systematic review finds mixed results for health information technology in enhancing coordinated care and improving health outcomes for people with multiple chronic conditions.

Longer participation in a patient-centered medical home is associated with better mental health care for people enrolled in Medicaid with major depressive disorder and multiple chronic conditions.