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

Details how two health plans in California developed programs to transition dually eligible members from institutional settings back into their communities.

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.

Peer recovery coaching intervention for hospitalized people with substance use disorder led to mixed acute care utilization outcomes.

Care management interventions for people transitioning from behavioral health inpatient care may be successful in decreasing readmissions if they address health-related social needs.

Inpatient addiction medicine consultation services reduced 90-day mortality for patients with substance use disorder after a hospital discharge, but showed mixed results on acute care utilization.

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

Care management interventions demonstrated improvements in mental health, quality of life, and patient satisfaction as well as reduced psychiatric inpatient days for people with serious mental illness.

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.

Behavioral health home model is associated with long-term changes in health services utilization for people with serious behavioral health conditions.

Home-based primary care did not decrease hospitalizations for people with dementia, but it did result in more patient- and family-centered end-of-life care.

Shared practical implementation considerations that can support health plans and provider groups in developing community-based models of care that use the strengths of social workers and community health workers.

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.

A community-based care transition and management intervention showed improved outcomes for patients transitioning to outpatient community care following a psychiatric hospitalization.

A participatory design approach created a nurse-driven screening process to better identify and treat people with opioid use disorder in the emergency department.

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