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

A mobile crisis response program in Denver reduced reports of low-level criminal offenses.

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

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

Resources to help organizations plan and implement medical respite care programs, including program development guides, case examples, and implementation tools.

Literature review examines the roles and contributions of community health workers in improving dementia 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.

A participatory design approach created a nurse-driven screening process to better identify and treat people with opioid use disorder in the emergency department.

Home-based palliative care providers explore key facilitators and barriers to effectively delivering care within a value-based payment environment.

Peer providers with lived experiences of substance use and mental health disorders can help improve patient outcomes and play a unique role in the behavioral health workforce.

A pharmacist-led substance use disorder intervention improved treatment retention for patients with opioid and alcohol use disorder.

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

During the COVID-19 pandemic, Cityblock Health implemented a virtually integrated care management model to maintain continuity of care for patients with complex needs.

Care team models with more nurse practitioners and physician assistants than physicians are associated with increased primary care and geriatrics services provision and reduced labor costs.

A Comprehensive Medication Management program that employs a remote clinical pharmacist effectively addresses most drug therapy problems in a complex care population.

CAPABLE, a home-based care program that provides interdisciplinary services for older adults, leads to reductions in disability as well as cost savings.

This toolkit shares business strategies, sample protocols, and best practice clinical tools for health care providers interested in developing a home-based palliative care program.

A home-based palliative care program using an interdisciplinary care team reduces hospital costs and unnecessary health care utilization for Medicare Advantage beneficiaries.

A community-based palliative care program reduced medical costs, intensive care unit (ICU) admissions, hospital admissions, and days spent in the hospital for Medicare Advantage members with serious illness.