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.

Downloadable tools, tip sheets, sample forms, and how-to guides on home-based primary care, with a focus on clinical and operational best practices.

People with multiple chronic conditions and disabilities enrolled in home-based primary care experienced persistent reduced acute care utilization.

A home-based primary care program decreases costs and utilization for high-risk Medicare enrollees in Washington D.C.

A home-based primary care program led to reduced medical costs for frail elderly patients, primarily due to lower spending at end-of-life.

Fostering a culture of caring for veterans takes interdisciplinary teams focused on comprehensive, trusting and reliable relationships through open and frequent communication and ongoing education.

Systematic review demonstrates the potential of home-based primary care interventions for improving heath, cost, and patient experience outcomes for adults with multiple chronic conditions and serious disabilities.

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