Identifies opportunities to strengthen integrated programs to improve care and support positive health outcomes for dually eligible individuals both during and beyond the pandemic.

Offers a practical framework for safety-net health systems to better identify and segment patients with complex needs, and tailor care models to meet their needs.

A complex care transitions pilot designed through a stakeholder-driven process led to decreased hospital utilization and costs.

For people with disabilities, familiarity with their care teams and care plans, and increased access to long-term services and supports can improve their perceptions of quality of life and health care.

This case study highlights an accountable care organization’s home-based primary care program for homebound older adults, with early analysis of outcomes showing reduced acute care utilization.

Medicare patients with the top five percent in preventable utilization account for almost half of all avoidable Medicare costs.

Explored opportunities for health systems and plans to work with CHW/Ps to support high-need individuals, with a focus on addressing the long-term impacts of the COVID-19 pandemic.

Using community health workers can reduce hospitalizations in high-risk patients.

A comprehensive overview of different funding approaches to sustainably finance CHW programs.

Strategies and a case example illustrate how principles of trauma-informed care can be applied to telehealth.

Training for caregivers of veterans living with dementia may help them remain in their home longer, but may lead to increased health care costs.

Step-by-step guide with robust tools for health systems to apply the 4Ms framework to deliver age-friendly, evidence-based care for older adults.

Highlighted innovations adopted by PACE organizations during the pandemic to provide care for older adults with complex needs.

Integrated health care systems can better support high-risk patients by embedding high-risk patient care within general primary care and mental health care.

Clinical tools, training resources, and case studies of evidence-based care models that support people living with dementia and their caregivers.

CHW intervention reduced health care costs and utilization for low-income women with depression.

Toolkit offers health care stakeholders in rural areas with practical information to support the design, implementation, and evaluation of community paramedicine programs.

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 randomized clinical trial of an 18-month comprehensive intervention showed significant reductions in cardiovascular disease risk in adults with serious mental illness.

Care coordination program reduces utilization for some high-cost, high-need Medicaid beneficiaries with diabetes.