An intensive care management intervention led to over $23,000 savings per year in total medical expenses for participating high-risk Medicaid ACO enrollees.

This description and application of a valid and reliable measure of equity of inpatient hospital experiences can help hospitals collect better data to meaningfully promote high-quality equitable care.

This toolkit can help providers and health systems better tailor care to fit the goals of each patient.

Summarizes evidence on costs of health-related social needs interventions and their impact on utilization and cost of care to inform ROI Calculator users.

When identifying patients with complex health needs for interventions, algorithms that rely on cost data as a proxy for health status may lead to under-identification of Black patients.

Nurses and members of fully staffed interdisciplinary care teams are more likely to use patient identification and care management tools.

Recommended set of evidence-based measures for high-quality care for patients with complex needs based on systematic review of relevant measures.

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

One health plan’s approach to addressing racial and ethnic disparities in medication adherence rates offers insights on levers to address racial inequities.

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

Natural language processing of patient visit notes can help providers identify social factors that may lead to health care utilization for older adults with multiple chronic conditions.

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.

Summarizes research on the prevalence of social screening in health care settings, validity of social screening tools, and patient and provider perspectives on social screening.

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.

Case managers noted establishing trust, fostering mindset changes, and increasing stability and independence can be measures of success when working with people with complex needs.

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.

With the steep increase in use of telehealth and video visits in the last few years, the reliance on technology-enabled medicine may heighten disparities in health care access.

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