A medical respite program for people experiencing homelessness shows evidence of reduced hospital readmissions and emergency department revisits.

This toolkit can support health care organizations in creating the business case for complex care programs.

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.

Understanding the values of patients with complex health and social needs can help providers improve care.

Black Medicaid enrollees who spent more days in the emergency department or county jail were less likely than white enrollees to receive medications for opioid use disorder.

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.