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
The Pharmacy Access to Resources and Medication for Opioid Use Disorder (PhARM-OUD) Guideline
Tool outlines expert recommendations to improve access to medications for opioid use disorder within community pharmacies.
Implementation Tool
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
Advancing Social Care Integration in Health Systems with Community Health Workers: An Implementation Evaluation Based in Bronx, New York
A community health worker initiative embedded in an urban health system led to a significant number of primary care patients receiving services to address their health-related social needs.
Peer-Reviewed Article
Building Successful Managed Care Programs with Community Health Workers’ Expertise
This brief offers tips for managed care organizations and Medicaid agencies on how to incorporate community health worker expertise when building or enhancing CHW programs.
Brief/Report
Environmental Scan on Community Health Workers: A 50-State Scan of Medicaid Reimbursement Approaches for the CHW Workforce
Comprehensive scan reveals diverse strategies in program design and provider reimbursement for community health worker services within state Medicaid programs.
Brief/Report
A Prescription Produce Program Integrating Lifestyle Behavior Counseling and Health Education: A Program Description and Evaluation
Analysis of a produce prescription and nutrition counseling program show promising results and key implementation insights.
Peer-Reviewed Article
2025 National Guidelines for a Behavioral Health Coordinated System of Crisis Care
Mental health service stakeholders can use this framework to assess and strengthen behavioral health crisis systems using established national guidelines.
Brief/Report
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
Neighborhood Nursing: Adapting a Universal, Community-Based Primary Care Model to Support Adults with Complex Needs
This webinar will spotlight the Neighborhood Nursing care model which uses an interdisciplinary approach to provide person-centered care for people with complex health and social needs.
Webinar
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