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.

Creating clinically meaningful profiles of patients with medically complex needs can support the delivery of more tailored interventions.

Implementing a predictive model in acute settings can more reliably identify patients with high mortality risk, which can assist providers in prioritizing advance care planning.

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.

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.

An integrated community health program demonstrated a cost savings of over three million dollars.

Use of machine learning clustering algorithms revealed 30 distinct subgroups of patients among high-risk veterans, indicating a need for tailored approaches to health care.

The 4Ms approach developed for the Age-Friendly Health System model — what matters, medication, mentation, mobility — has a robust evidence base for providing quality care to older adults.

Medication management interventions that support caregivers of people with dementia at care transitions can help reduce readmissions, caregiver burden, and use of high-risk medication.

Discusses the benefits and challenges of tele-social care and offers practical tips for providers administering telehealth services for social care activities.

Many physicians report low confidence in caring for patients with disability and negative perceptions about quality of life with a disability, which may reflect biased views that potentially contribute to persistent health disparities.

Patients with dementia are more likely to be discharged to hospice from hospitals that offer palliative care programs.

Evaluates the evidence on interventions for people living with dementia, their care partners, and caregivers to help identify what interventions are ready for broad implementation.

Suggests that community-based organizations are responding to Medicaid redesign efforts that prioritize social determinants of health by adopting practices similar to health care organizations.

Enhanced primary care for adults with serious mental illness led to increases in primary care visits and health screenings as well as decreases in inpatient utilization.