People with Behavioral Health and Social Needs Resources

This resource describes and evaluates a new specialist pharmacy service, called the integrated care clinical pharmacist.

This resource analyzes preventable ED visits and identifies mechanisms for preventing them.

At Northwestern Medical Group in Chicago, a patient-centered transitional care intervention serving patients with complex health needs that lack a usual source of care was f

This resource highlights a variety of prevention-focused programs, initiatives and strategies (plays) focused on the opioid use epidemic.

This resource is a toolkit to help payers and providers understand how home-based primary care (HBPC) improves quality and reduces costs for seriously ill and home-limited o

This resource identifies challenges faced by older adults from racial and ethnic minorities, and proposes several strategies to address them.

This resource provides an example of an approach to caring for different subpopulations of people with dementia. 

This resource describes a randomized controlled trial to evaluate the effects of a case management intervention called V1SAGES (Vulnerable Patients in Primary Care: Nurse Ca

This resource describes an effort to apply a learning health systems approach to reducing ED utilization.

This resource is a toolkit highlighting innovative care coordination strategies used by Medicare ACOs.

This resource is a toolkit for identifying patients with various physical, functional, emotional, social, and spiritual needs.

This resource is a study evaluating an alternative in-hospital assessment to determine the need for continuing care after discharge.