Recommendations for building a stronger, more coordinated, and patient-centered complex care evidence base.

Community-based care management programs for patients with complex health and social needs have the potential to reduce hospitalizations and inpatient costs.

Program based in affordable housing sites for older adults and people with disabilities has favorable impact on Medicare and Medicaid expenditures and helps residents remain in community settings.

Interdisciplinary primary care models can help reduce acute care use for individuals with histories of high emergency department use, homelessness, or substance use disorder.

Systematic review finds that medical respite programs reduce acute care utilization outcomes for people experiencing homelessness.

A permanent supportive housing program did not improve most measures related to physical health for individuals experiencing chronic homelessness, but did improve access to and trust in primary care.

Resources to help organizations plan and implement medical respite care programs, including program development guides, case examples, and implementation tools.

Literature review examines the roles and contributions of community health workers in improving dementia care.

Patients and community health workers (CHWs) share perspectives on the impact of CHW services provided within a primary care setting to address barriers to equitable care.

Explored how complex care stakeholders can incorporate a multi-factor approach to measure and demonstrate the value of complex care programs for diverse stakeholders.

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

CAPABLE, a home-based care program that provides interdisciplinary services for older adults, leads to reductions in disability as well as cost savings.

Examines how home meal delivery programs show promise for reducing the use of costly health care and decreasing spending for dually eligible individuals.

California’s Whole Person Care pilot can inform cross-sector initiatives to improve care for Medicaid enrollees with complex health and social needs.

Supportive housing placement for people with substance use disorder (SUD) who are homeless reduces SUD-related health care utilization.

This resource is an updated quick reference guide to promising models for people with complex needs.

A regional approach to health care transformation.

Difficulty with activities of daily living is a major cost driver in health care that is typically overlooked.

Care management programs should include processes for evaluating patient-reported outcomes.

By closing gaps in care, a safety-net ACO has reduced medical costs for Medicaid patients with complex needs.