This toolkit supports organizations to bill for community health workers/promotores interventions.

Medicaid health plan-led community health worker program showed moderate evidence for increased outpatient care and primary care use.

Well-designed bidirectional community and referral pathways may help bridge the community-clinic divide.

State investments in enhanced primary care for older and chronically ill individuals recently released from incarceration yielded a $2.55 return on investment for Medicaid and criminal justice combined.

Social and legal services to address health care costs and utilization may be most effective for individuals with moderately high utilization who are less clinically complex.

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.

Study details permanent supportive housing program implementation and how this impacts outcomes and costs.

Simulation model estimates that national implementation of medically tailored meal programs for specific populations would achieve over $13.6 billion in cost savings per year.

A hospital-based program showed that peer recovery coaching can be seamlessly integrated into the workflow of busy emergency departments to address the longer-term needs of people with substance use disorders.

Summarizes evidence on costs of health-related social needs interventions and their impact on utilization and cost of care to inform ROI Calculator users.

Patients with higher ACEs scores or positive PTSD screenings felt stress when seeking medical care, but indicated trauma-informed treatment approaches would relieve this stress.

Summarizes research on the prevalence of social screening in health care settings, validity of social screening tools, and patient and provider perspectives on social screening.

Partnerships between health care organizations and AAAs can benefit from a clear understanding of internal capabilities and external environmental factors.

Case managers noted establishing trust, fostering mindset changes, and increasing stability and independence can be measures of success when working with people with complex needs.

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.

Medicaid enrollees in a community health worker program had fewer emergency department visits and more outpatient ambulatory care use than beneficiaries who received usual care.

With the steep increase in use of telehealth and video visits in the last few years, the reliance on technology-enabled medicine may heighten disparities in health care access.

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.

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

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.