Contains practical guides, tools, and other resources for developing complex care programs.

Randomized controlled trial of a care management intervention shows significant improvement in patient activation and self-rated health and decreased symptoms of depression in patients with complex needs.

A Medicaid health home care management program led to improved diabetes care, benefitting people with co-occurring substance use disorders and diabetes.

Profile of a geriatric emergency department model for older adults with complex needs includes sample policies and workflows as well as recommendations to support effective implementation.

Use of hospital readmission rates to measure quality may be unfair for some accountable care organizations and safety-net providers, since members with complex medical and social needs are a main driver of these rates.

Synthesis of studies on effective home-based palliative care emphasizes essential elements for creating a quality program.

This toolkit shares business strategies, sample protocols, and best practice clinical tools for health care providers interested in developing a home-based palliative care program.

A home-based palliative care program in a full-risk financial arrangement showed consistent cost savings and lower hospital utilization across a 10-year period.

A home-based palliative care program using an interdisciplinary care team reduces hospital costs and unnecessary health care utilization for Medicare Advantage beneficiaries.

A community-based palliative care program reduced medical costs, intensive care unit (ICU) admissions, hospital admissions, and days spent in the hospital for Medicare Advantage members with serious illness.

Creating a palliative care program to meet the needs of low-income communities requires solutions that are patient centered and supportive of the clinical care team.

Care model that integrates home-based primary care and palliative care for patients with serious illness reports reduced health care utilization and improved patient care experience.

Home-based palliative care program implemented within an accountable care organization created cost savings through reduced hospital admissions and increased hospice length of stay.

Tailoring palliative care interventions for people who are members of ethnic and racial minority groups may support increased access to palliative care and end of life services.

Presents a framework and tools to help health care organizations and communities design a community-based palliative care program to meet patient needs in rural settings.

This case study analyzes a successful example of a medical group partnering with a home health agency to provide community-based palliative care for high-risk members of their accountable care organization.

Evidence-based intervention at a behavioral health home improved health outcomes for patients with co-occurring type 2 diabetes and serious mental illness.

Community health worker-led interventions for older adults with complex needs show evidence of improving participant mood and functional outcomes.

Clearly defining characteristics of complex populations is essential for effective complex care intervention design.

Case studies and lessons from evidence-based interventions to address social isolation and loneliness in older adults.