Guidance on partnering with community-based organizations to provide services such as meal delivery and transportation for dually eligible individuals.

An affordable housing program in Baltimore generates between $1.30-$1.92 of “social return” in the community for every dollar invested annually.

Step-by-step guide with robust tools for health systems to apply the 4Ms framework to deliver age-friendly, evidence-based care for older adults.

Home-based primary care programs enable care teams to gain insights on a variety of social factors that impact older adults’ health, which allows them to better tailor care to meet patient needs.

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

Analysis of recent and projected growth of expanded supplemental benefits offered by Medicare Advantage plans — such as meals, transportation, and in-home support services.

Examines the early implementation of Medicare Advantage expanded supplemental benefits, along with policy considerations to promote plan adoption and beneficiary access to these benefits.

Suggests that community-based organizations are responding to Medicaid redesign efforts that prioritize social determinants of health by adopting practices similar to health care organizations.

Provides practical steps for current or potential future Medicare accountable care organizations to transform the delivery of care, including through telehealth, home visits, and skilled nursing care.

Offers a practical framework for safety-net health systems to better identify and segment patients with complex needs, and tailor care models to meet their needs.

Provides an overview of home-based medical care models, the patients that they serve, and their robust evidence base.

Includes promising practices, recommendations, vignettes, and other helpful tools to assist health systems in supporting family caregivers providing complex care.

Describes factors that support health care organizations in transitioning from volume- to value-based payment.

Summarizes different approaches and criteria that can be used to identify patients with complex needs for health system interventions.

Demonstrates that a program assisting older adults with complex needs in navigating medical and social services may lower acute care utilization.

Contains strategies, tips, and case studies to assist health care stakeholders in building meaningful, person-centered engagement in their organizations.

Examines the potential for Minnesota’s integrated care model to lower use of hospital care and increase use of primary care and community-based services for dually eligible older adults.

Identifies opportunities to strengthen integrated programs to improve care and support positive health outcomes for dually eligible individuals both during and beyond the pandemic.

Explores different characteristics of dually eligible individuals that have different coverage types, as well as the impact of aligned Medicare and Medicaid benefits to improve quality of care and utilization outcomes.

Poses key questions to help states new to Medicare-Medicaid integration assess readiness for integration and select an achievable integration approach.