Home-based primary care program reduced hospitalizations for older adults with diabetes, especially those with higher levels of medical complexity.

Home-based primary care integrated with long-term services and supports in the community can delay long-term institutionalization in frail older adults without increased costs for home- and community-based services.

Strategies for home-based primary care practices to improve efficiency and support program growth based on qualitative research.

This case study highlights an accountable care organization’s home-based primary care program for homebound older adults, with early analysis of outcomes showing reduced acute care utilization.

Shares best practices and screening tool options to identify and care for home-based primary care patients with potential fall risks.

The Department of Veterans Affairs home-based primary care program reduced total costs of care for VA and Medicare and earned high satisfaction ratings from patients and their caregivers.

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.

Disparities in transitional care training for caregivers of older adults based on race or financial status demonstrate need for changes in discharge processes and strategies to address bias.

Toolkit details how hospitals and health systems can use patient race, ethnicity, and language data to advance health equity and eliminate disparities.

Home-based intensive care model for Medicaid and dually eligible enrollees with complex needs led to positive health outcomes and reduced acute care spending, particularly for individuals with a behavioral health diagnosis.

The 4Ms approach developed for the Age-Friendly Health System model — what matters, medication, mentation, mobility — has a robust evidence base for providing quality care to older adults.

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.

Step-by-step guide with robust tools for health systems to apply the 4Ms framework to deliver age-friendly, evidence-based care for older adults.

Home-based primary care programs enable care teams to gain insights on a variety of social factors that impact older adults’ health, which allows them to better tailor care to meet patient needs.

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

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.

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

Demonstrates that a program assisting older adults with complex needs in navigating medical and social services may lower acute care utilization.