Lower inpatient admissions rates in a transitional care intervention.

How ACOs are addressing serious illness.

Strategies for preventing opioid use disorder.

This toolkit details the benefits of home-based primary care to help providers demonstrate the need for these programs.

Improving Dementia Care

Predictive modeling to reduce ED utilization.

The psychological benefits of case management.

Includes case studies, clinical assessment tools, and other resources for identifying and assessing the needs of patients with serious illness.

Assessing post-discharge needs.

Challenges and opportunities for older adults with multiple chronic conditions.

Includes national survey data on family caregivers and their experiences in managing complex medical and nursing tasks for their family members at home, as well as recommendations to improve the supports for family caregivers.

Video series details how health systems can redesign primary care, including through home-based primary care programs, to better meet the needs of people with disabilities.

A tool for assessing readiness for value-based partnerships.

Improving communication with patients with advanced cancer

The importance of timely primary care follow-up.

An in-depth overview of different personas.

This resource is an updated quick reference guide to promising models for people with complex needs.

Maximizing the impact of outpatient complex case management.

The case conference approach to caring for complex patients.

An international analysis of high-cost patients.