Advance care planning more than one month prior to death is associated with decreased acute care utilization at the end of life and in-hospital death for people with serious illness.

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.

A Medicaid health home care management program led to improved diabetes care, benefitting people with co-occurring substance use disorders and diabetes.

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.

Evidence-based intervention at a behavioral health home improved health outcomes for patients with co-occurring type 2 diabetes and serious mental illness.

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.

Creating clinically meaningful profiles of patients with medically complex needs can support the delivery of more tailored interventions.

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.

Evaluates the evidence on interventions for people living with dementia, their care partners, and caregivers to help identify what interventions are ready for broad implementation.

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

Clinical tools, training resources, and case studies of evidence-based care models that support people living with dementia and their caregivers.

Many physicians report low confidence in caring for patients with disability and negative perceptions about quality of life with a disability, which may reflect biased views that potentially contribute to persistent health disparities.

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

Medication management interventions that support caregivers of people with dementia at care transitions can help reduce readmissions, caregiver burden, and use of high-risk medication.

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.

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.