Implementation of the Age-Friendly Health Systems approach within a Federally Qualified Health Center can improve patient care process outcomes and improve access to care for rural older adults.

Initiative successfully implemented several evidence-based and promising addiction care models across multiple medical settings, including an inpatient addiction consult team, a low-threshold bridge clinic, peer recovery coaches, and office-based addiction treatment nurses.

Highlighted two community paramedicine programs in New England and rural North Carolina that serve people with complex needs.

An intensive care management intervention led to over $23,000 savings per year in total medical expenses for participating high-risk Medicaid ACO enrollees.

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.

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.

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

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

A permanent supportive housing program did not improve most measures related to physical health for individuals experiencing chronic homelessness, but did improve access to and trust in primary care.

Behavioral health home model is associated with long-term changes in health services utilization for people with serious behavioral health conditions.

Home-based primary care did not decrease hospitalizations for people with dementia, but it did result in more patient- and family-centered end-of-life care.

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.

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

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

Tools, tips, and vignettes for incorporating telehealth into home-based primary care models.

Downloadable tools, tip sheets, sample forms, and how-to guides on home-based primary care, with a focus on clinical and operational best practices.

People with multiple chronic conditions and disabilities enrolled in home-based primary care experienced persistent reduced acute care utilization.