Recommendations for policymakers, health plans, and providers on implementing medically tailored meals programs.

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.

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

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

Randomized controlled trial of a person-centered housing intervention for older adults shows improved health outcomes for formerly homeless adults living in permanent supportive housing.

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

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

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.

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.

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

Home-based primary care program reduced hospitalizations for older adults with diabetes, especially those with higher levels of medical complexity.

Home-based intensive care model for Medicaid and dually eligible enrollees with complex needs led to positive health outcomes and reduced acute care spending, particularly for individuals with a behavioral health diagnosis.

Patients with dementia are more likely to be discharged to hospice from hospitals that offer palliative care programs.

A complex care transitions pilot designed through a stakeholder-driven process led to decreased hospital utilization and costs.

The benefits of a transitional care program.

How home visits are used by ACOs to improve care, lower costs.

Lower inpatient admissions rates in a transitional care intervention.