Home-Based Primary Care Visits by Nurse Practitioners
Home-based primary care nurse practitioners improve health outcomes for homebound older adults.
Peer-Reviewed Article
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Clinicians and Promotores Teaming to Provide In-Home Primary Care to Frail Older Adults
Pairing promotores with clinicians increased in-home visits and reduced acute care use and health care costs for homebound older adults.
Case Example
Bridges to Elders: A Program to Improve Outcomes for Older Women Experiencing Homelessness
Program led by a nurse practitioner and community health worker improved housing stability, access to primary care, and chronic disease management among older women experiencing homelessness.
Peer-Reviewed Article
Cost-Effective Care Coordination for People with Dementia at Home
A multidisciplinary care coordination program for older adults with dementia demonstrated a positive return on investment and Medicaid cost savings.
Peer-Reviewed Article
Diabetes Management Among Underserved Older Adults Through Telemedicine and Community Health Workers
Research review finds that incorporating community health workers into primary care reduced A1c levels and improved self-management and satisfaction among older adults with diabetes.
Peer-Reviewed Article
Understanding the Medicare Physician Fee Schedule Billing Codes For: Community Health Integration, Principal Illness Navigation, and Principal Illness Navigation-Peer Support Services
This toolkit details options for implementing recently introduced Medicare services that address members’ health-related social needs.
Implementation Tool
Pharmacist-Provided Medication Therapy Management in Medicaid
Brief provides overview of medication therapy management in Medicaid to support members with multiple chronic conditions.
Brief/Report
Opportunities for Public Health Agencies to Advance Sustainable Financing of Community Health Worker Programs
Report highlights key strategies for supporting financially sustainable community health worker programs.
Brief/Report
Implementing and Monitoring High-Quality Community Health Worker Care in Adult Primary Care at New York City Health + Hospitals
This study offers a standardized approach for embedding community health workers into primary care, providing a valuable framework for health systems aiming to integrate this workforce.
Peer-Reviewed Article
Assessing the Impact of Community-Based Mobile Crisis Services on Preventing Hospitalization
A mobile crisis program reduced hospitalization rates among individuals experiencing behavioral health crises.
Peer-Reviewed Article
Mobile Crisis Teams for Adults with Complex Needs: Evidence Roundup
Explores evidence on the effectiveness of mobile crisis teams for adults experiencing behavioral health crises and recent funding opportunities that can help scale and implement these vital services.
Blog
January 2025
Naloxone Co-Dispensing with Opioids: A Cluster Randomized Pragmatic Trial
Pharmacy co-dispensing of naloxone with opioid prescriptions improved naloxone receipt and overdose prevention knowledge without encouraging risk behaviors.
Peer-Reviewed Article
Facilitating Exit From Encampments: Combining Low-Barrier Transitional Housing with Stabilizing Treatment for Substance Related Problems
Transitional housing, combined with co-located substance use disorder care, facilitates access to permanent housing and increases engagement in substance use treatment.
Peer-Reviewed Article
Outcomes of an Integrated Practice Unit for Vulnerable Emergency Department Patients
Multidisciplinary integrated practice units may have a greater impact on acute care utilization by focusing on patients who have high utilization of emergency departments and are uninsured.
Peer-Reviewed Article
Thirty-Day Hospital Readmission Among Homeless Individuals with Medicaid in Massachusetts
Discharge to medical respite care leads to lower hospital readmission rates among individuals who are frequently admitted to the hospital.
Peer-Reviewed Article
Medical Respite Literature Review: An Update on the Evidence for Medical Respite Care
A review of existing literature finds that medical respite care reduces hospital and emergency department visits, increased use of outpatient care, and leads to overall cost savings.
Brief/Report
Peer Recovery Services for Persons Returning from Prison: Pilot Randomized Clinical Trial Investigation of SUPPORT
Peer recovery services offered to people with substance use disorder returning to community from incarceration is shown to reduce substance use and improve health and treatment motivation.
Peer-Reviewed Article
Best Practices for Successful Reentry From Criminal Justice Settings for People Living With Mental Health Conditions and/or Substance Use Disorders
Toolkit offers guidance for corrections and health care professionals on evidence-based interventions to support the reentry needs of people with behavioral health needs.
Implementation Tool
Collaborative Comprehensive Case Plans
Web-based tool offers guidance and examples for cross-sector case planning for adults with behavioral health needs leaving jails and prisons.
Implementation Tool
A Systematic Review of Post-Release Programs for Women Exiting Prison with Substance-Use Disorders: Assessing Current Programs and Weighing The Evidence
Systematic review finds that gender-response programs are associated with reductions in reincarceration for women with substance use disorder leaving jail or prison.
Peer-Reviewed Article