Resources

Veterans frequently have complex medical, behavioral, and social needs, but often experience barriers in accessing health care services from the Department of Veterans Affairs (VA), the largest...
While community health worker (CHW) programs that serve low-income populations have demonstrated reductions in preventable acute care utilization, these programs often have limited funding. Developing...
Whole Person Care (WPC) pilots, under California’s Medicaid Section 1115(a) waiver demonstration, integrate medical, behavioral health, and social needs services to improve the health and wellbeing of...
Health care organizations are increasingly partnering with Area Agencies on Aging (AAAs) to provide social needs support for older adults in the community who are identified with high health risks...
Individualized Management for Patient-Centered Targets (IMPaCT) is an intervention that employs community health workers to provide tailored social support to high-risk patients informed by patient...
High-need, high-cost Medicaid patients enrolled in a 12-month complex care management program at CareMore Health in Memphis, Tennessee experienced reductions of 59 percent in inpatient utilization and...
A randomized controlled trial found that the “Camden Core Model,” a short-term care management program for individuals with complex health and social needs and multiple recent hospital admissions, did...
This resource describes a quasi-experimental study evaluating the effect of a transitional care program that involved rapid primary care follow-up for Medicaid and Medicare patients with complex needs...
This study compared health services use and costs depending on whether the primary care provider was a physician, NP, or PA. NPs and PAs are taking a larger role in the primary care of medically...
This resource describes a study of how health care providers and social services providers coordinate their work in communities that achieve relatively low health care utilization and costs for older...
This resource assesses HealthChoices HealthConnections, an integration pilot program for Medicaid beneficiaries with SMI and co-occurring chronic conditions in three Pennsylvania counties. Better data...
This resource provides a literature review of existing empirical evidence about the impact of social service interventions on health outcomes and health care spending, based on 39 articles published...