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.

A health-related quality of life measure can be a leading indicator for future adverse health outcomes for older adults.

Varying structures of cross-sector partnerships between health care organizations, social service agencies, and local government bodies have distinct strengths and serve different functions.

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.

Accountable care organization leaders share perspectives on payment mechanisms used with social service organizations, challenges experienced, and the impacts of these partnerships.

Advancing more equitable access to telehealth may require care coordination strategies deployed alongside telehealth.

Using segmentation to address clinical and social needs for Medicaid patients with complex needs and costly utilization can improve the effectiveness of complex care programs.

Differing patterns of care utilization and mortality outcomes within subgroups of a complex patient population can help inform more targeted care interventions.

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

Global budgets for hospitals reduced expenditures and utilization for some Medicare subpopulations with complex health and social needs, yet disparities existed for some subgroups.

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.

Telehealth interventions had similar outcomes to in-person care for different services and populations, but did not consistently impact utilization such as physician or emergency department visits.

Offers practical recommendations to improve telemedicine interventions to be more equitable for diverse populations, particularly those with low incomes.

Describes electronic health record system functionality that automatically identifies patients likely to need technical assistance prior to telehealth visits.

During the COVID-19 pandemic, Cityblock Health implemented a virtually integrated care management model to maintain continuity of care for patients with complex needs.

Discusses the benefits and challenges of tele-social care and offers practical tips for providers administering telehealth services for social care activities.