Medicare beneficiaries with dementia, especially Black and Hispanic patients, often receive poor quality end-of-life care.

Summarizes research on the prevalence of social screening in health care settings, validity of social screening tools, and patient and provider perspectives on social screening.

Analytical approach for randomized controlled trials may be valuable for understanding the impact of complex care interventions and the subpopulations that may benefit from them.

Community-based care management programs for patients with complex health and social needs have the potential to reduce hospitalizations and inpatient costs.

Evidence map of patient and family engagement strategies highlights range of evidence on self-management support and shared decision-making.

This guide describes key strategies for health plans, accountable care organizations, and health systems to improve care for people with serious illness.

Describes the core elements and evidence base behind a home- and community-based palliative care model that was designed by stakeholders to support the health needs of people with serious illness.

Explored how complex care stakeholders can incorporate a multi-factor approach to measure and demonstrate the value of complex care programs for diverse stakeholders.

Home-based palliative care providers explore key facilitators and barriers to effectively delivering care within a value-based payment environment.

Segmentation framework with publicly available code files identifies specific and actionable patient cohorts with complex needs.

Using segmentation to address clinical and social needs for Medicaid patients with complex needs and costly utilization can improve the effectiveness of complex care programs.

Looked at the provider and payer relationship and discussed how successful partnerships between these two stakeholders can create sustainable and efficacious home and community based palliative care programs.

A street medicine program increased post-hospitalization follow-up care for unsheltered individuals experiencing homelessness in Los Angeles.

Home-based palliative care program implemented within an accountable care organization created cost savings through reduced hospital admissions and increased hospice length of stay.

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

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

Over 14 years, individuals experiencing chronic homelessness enrolled in a permanent supportive housing program had low housing retention and high mortality.

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

Provides an overview of home-based medical care models, the patients that they serve, and their robust evidence base.

Health care organizations can use population-level data sources about the experiences of people with disabilities to improve care.