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.

Home-based program provided by a community health and social worker reduces acute care use and improves care for older adults with complex health and social needs.

A care coordination and palliative care intervention for adults with complex needs was associated with significantly reduced short-term mortality.

Federal home-based primary care demonstration showed mixed results on measures related to Medicare savings, care quality, and utilization for Medicare-only and dually eligible beneficiaries.

Personalized patient navigation supports for people with comorbid substance use disorders reduced rates of hospital readmissions and emergency department use.

Home-based intensive care model for Medicaid and dually eligible enrollees with complex needs led to positive health outcomes and reduced acute care spending, particularly for individuals with a behavioral health diagnosis.

Provides an overview of home-based medical care models, the patients that they serve, and their robust evidence base.

Demonstrates that a program assisting older adults with complex needs in navigating medical and social services may lower acute care utilization.

Indicates that a community-based nurse care management model reduced all-cause mortality for older adults with chronic conditions.