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

Toolkit can help guide implementation of integrated care teams into primary care settings.

Clearly defining characteristics of complex populations is essential for effective complex care intervention design.

Contains practical guides, tools, and other resources for developing complex care programs.

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

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.

Profile of a geriatric emergency department model for older adults with complex needs includes sample policies and workflows as well as recommendations to support effective implementation.

Includes patient- and staff-reported measures to help complex care programs better understand the impacts of interventions.

A comprehensive review of state mechanisms to reimburse for community health worker services.

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

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

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

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

Primary care and alternative payment models that reduce emergency department use and increase access to care for high-need populations share core components for success.

Disparities in transitional care training for caregivers of older adults based on race or financial status demonstrate need for changes in discharge processes and strategies to address bias.

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.

An affordable housing program in Baltimore generates between $1.30-$1.92 of “social return” in the community for every dollar invested annually.

Toolkit details how hospitals and health systems can use patient race, ethnicity, and language data to advance health equity and eliminate disparities.

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