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.

Creating clinically meaningful profiles of patients with medically complex needs can support the delivery of more tailored interventions.

Use of machine learning clustering algorithms revealed 30 distinct subgroups of patients among high-risk veterans, indicating a need for tailored approaches to health care.

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.

Implementing a predictive model in acute settings can more reliably identify patients with high mortality risk, which can assist providers in prioritizing advance care planning.

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.

Clinical tools, training resources, and case studies of evidence-based care models that support people living with dementia and their caregivers.

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.

Many physicians report low confidence in caring for patients with disability and negative perceptions about quality of life with a disability, which may reflect biased views that potentially contribute to persistent health disparities.

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

Medication management interventions that support caregivers of people with dementia at care transitions can help reduce readmissions, caregiver burden, and use of high-risk medication.

Suggests that community-based organizations are responding to Medicaid redesign efforts that prioritize social determinants of health by adopting practices similar to health care organizations.

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.