For people with disabilities, familiarity with their care teams and care plans, and increased access to long-term services and supports can improve their perceptions of quality of life and health care.

Segmentation framework with publicly available code files identifies specific and actionable patient cohorts with complex needs.

Explored how health care organizations can incorporate a segmentation framework into population health management using simple algorithms.

A cross-sector partnership to enroll older adults experiencing homelessness in permanent supportive housing led to meaningful reductions in health care costs.

Contains practical guides, tools, and other resources for developing complex care programs.

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.

Primary care and alternative payment models that reduce emergency department use and increase access to care for high-need populations share core components for success.

Personalized patient navigation supports for people with comorbid substance use disorders reduced rates of hospital readmissions and emergency department use.

Use of machine learning clustering algorithms revealed 30 distinct subgroups of patients among high-risk veterans, indicating a need for tailored approaches to health care.

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

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

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

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

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

Examines promising strategies to meet the needs of dually eligible individuals with serious mental illness, with an emphasis on opportunities to innovate with flexible spending within a capitated payment model.

Details how dually enrolled beneficiaries have significantly higher levels of comorbidities and higher costs of care than their non-dually enrolled counterparts.

Demonstrates that intensive outpatient care programs show promise in reducing utilization and costs and improving patient outcomes for high-need, high-cost populations.

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

Medicare patients with the top five percent in preventable utilization account for almost half of all avoidable Medicare costs.