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.

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.

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.

Care management interventions demonstrated improvements in mental health, quality of life, and patient satisfaction as well as reduced psychiatric inpatient days for people with serious mental illness.

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 community-based care transition and management intervention showed improved outcomes for patients transitioning to outpatient community care following a psychiatric hospitalization.

Systematic review of programs to improve care for patients with complex needs details evidence base across multiple settings.

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.

Details implementation guidance for the evidence-based Care Ecosystem model, which improves supports for people with dementia and their caregivers.

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

Randomized controlled trial of a care management intervention shows significant improvement in patient activation and self-rated health and decreased symptoms of depression in patients with complex needs.

A Medicaid health home care management program led to improved diabetes care, benefitting people with co-occurring substance use disorders and diabetes.

Evidence-based intervention at a behavioral health home improved health outcomes for patients with co-occurring type 2 diabetes and serious mental illness.

Community health worker-led interventions for older adults with complex needs show evidence of improving participant mood and functional outcomes.