Opportunities for identifying the financial value of dementia care to support positive return on investment.

Community health worker interventions are effective for improving health behaviors and outcomes and reducing health care costs for people with chronic disease.

Assigning dually eligible individuals with mental illness to ACOs was associated with shifts to lower-cost outpatient settings, but did not affect overall spending and utilization.

Including spiritual care within care management programs in outpatient, managed care, and population health settings can enhance patient care and support the effectiveness of the interdisciplinary care team.

Highlighted two community paramedicine programs in New England and rural North Carolina that serve people with complex needs.

A home-based urgent care program for frail, homebound older adults did not reduce emergency department visits, hospitalizations, or total medical expenditure.

An intensive care management intervention led to over $23,000 savings per year in total medical expenses for participating high-risk Medicaid ACO enrollees.

Describes a primary care organization’s approach to using machine learning versus provider judgement to assign primary care visit frequency and better identify future risk of hospitalization and medical cost.

A short-term emergency department navigator program helped address acute care utilization for individuals with low baseline utilization through primary care follow up appointments and assistance with social needs.

A "virtual-first" transitional care program with an interdisciplinary care team can support reduced readmissions.

Described how health care organizations and community-based organizations can use the ROI Calculator to explore and plan financial arrangements to fund social services for people with complex needs.

Describes the core elements and evidence base behind a home- and community-based palliative care model that was designed by stakeholders to support the health needs of people with serious illness.

This guide describes key strategies for health plans, accountable care organizations, and health systems to improve care for people with serious illness.

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

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.

Home-based palliative care providers explore key facilitators and barriers to effectively delivering care within a value-based payment environment.

A pharmacist-led substance use disorder intervention improved treatment retention for patients with opioid and alcohol use disorder.

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

Systematic review finds mixed results for health information technology in enhancing coordinated care and improving health outcomes for people with multiple chronic conditions.