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

A health plan-led telepsychiatry program for older adults can address the shortage of psychiatrists to improve outcomes related to depression and access to mental health care.

A patient intervention that supported outpatient addiction treatment with destigmatized conversations about substance use between patients and primary care providers showed long-term benefits.

Featured presenters with on-the-ground experience implementing the CA Bridge model for individuals with substance use disorder.

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

One health plan’s approach to addressing racial and ethnic disparities in medication adherence rates offers insights on levers to address racial inequities.

Virtual collaborative care intervention demonstrates an approach to improve medication adherence and health outcomes.

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.

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

Guide for hospitals to address housing instability by understanding the evidence, evaluating different approaches, and exploring case studies of health system-led programs.

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.

Telephone- and web-based dementia care provided through centralized hubs and delivered by an interdisciplinary team can improve outcomes for people with dementia and their caregivers.

An interdisciplinary team approach can improve care coordination and reduce length of hospital stays for older adults with complex health and social needs.

A medical respite program for people experiencing homelessness shows evidence of reduced hospital readmissions and emergency department revisits.

A practical guide for payers to create a home-based palliative care program centered upon a value-based case example from a payer’s perspective.

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.