Recommendations for building a stronger, more coordinated, and patient-centered complex care evidence base.

A patient navigation intervention for people with substance use disorder led to cost savings of over $17,000 per participant after 12 months post-discharge due to reduced inpatient admissions and emergency department visits.

Patients with complex needs were more satisfied with in-home urgent care delivered by community paramedics than with emergency department urgent care.

Describes a primary care organization’s approach to using machine learning versus provider judgement to assign primary care visit frequency and better identify future risk of hospitalization and medical cost.

Analytical approach for randomized controlled trials may be valuable for understanding the impact of complex care interventions and the subpopulations that may benefit from them.

Black caregivers of people with dementia share their perspectives on a care coordination intervention.

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

A short-term emergency department navigator program helped address acute care utilization for individuals with low baseline utilization through primary care follow up appointments and assistance with social needs.

Medicaid enrollees in a community health worker program had fewer emergency department visits and more outpatient ambulatory care use than beneficiaries who received usual care.

A "virtual-first" transitional care program with an interdisciplinary care team can support reduced readmissions.

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

Community-based care management programs for patients with complex health and social needs have the potential to reduce hospitalizations and inpatient costs.

Partnerships between community-based organizations and primary care providers can improve depression care for older adults.

Program based in affordable housing sites for older adults and people with disabilities has favorable impact on Medicare and Medicaid expenditures and helps residents remain in community settings.

Peer recovery coaching intervention for hospitalized people with substance use disorder led to mixed acute care utilization outcomes.

Care management interventions for people transitioning from behavioral health inpatient care may be successful in decreasing readmissions if they address health-related social needs.

Inpatient addiction medicine consultation services reduced 90-day mortality for patients with substance use disorder after a hospital discharge, but showed mixed results on acute care utilization.

Interdisciplinary primary care models can help reduce acute care use for individuals with histories of high emergency department use, homelessness, or substance use disorder.