Evidence Bank

The Evidence Bank is a collection of research studies on common services provided by CBOs that demonstrate outcomes attractive to a health care partner. This collection is updated on a bimonthly basis. For more information, read our Explanations and Instructions page.

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Disease Management August 19, 2022 Take Heart Background and Objectives To assess the impact of an evidence-based self-management intervention adapted through a community-engaged process for African American midlife and older adults with heart disease and/or cardiovascular risk factors. Research Design and Methods Adults... Read More
Housing Plus Services October 1, 2018 Selfhelp Active Services for Aging Model (SHASAM) Background/objectives: There is strong evidence that housing conditions affect population health, but evidence is limited on the extent to which housing with supportive social services can maintain population health and reduce the use of expensive hospital services. Purpose: To asses... Read More
Care Management/Care Coordination, Home Modification, Meals and Nutrition, Social Engagement, Transportation September 1, 2022 Guide to Evidence for Health-Related Social Needs Interventions: 2022 Update The Commonwealth Fund released a review of evidence regarding health-related social needs interventions, which is intended to help inform users of its Return on Investment (ROI) Calculator for Partnerships to Address the Social Determinants of Health. It summarizes the authors’ assessme... Read More
Caregiving, Home care, Home Modification, Institutional Transition, Meals and Nutrition April 26, 2022 CalAIM Community Supports: Promoting Independent Living Among Older Adults and People with Disabilities Through CalAIM (California Advancing and Innovating Medi-Cal), a multiyear initiative to transform California’s Medi-Cal, or Medicaid, program, managed care plans (MCPs) now have the option to offer any of 14 Community Supports that provide person-centered services to address a variety ... Read More
Meals and Nutrition April 2, 2018 Medically Tailored Meals Participants: The participants were members of Commonwealth Care Alliance (CCA), a not-for-profit community-based health plan that manages and administers care for adults older than age twenty-one who are dually eligible for Medicaid and Medicare. All CCA members with at least six mont... Read More
Care Management/Care Coordination, Home Modification November 22, 2017 Community Aging in Place, Advancing Better Living for Elders (CAPABLE) Background/objectives: Little is known about cost savings of programs that reduce disability in older adults. The objective was to determine whether the Community Aging in Place, Advancing Better Living for Elders (CAPABLE) program saves Medicaid more money than it costs to provide. D... Read More
Care Management/Care Coordination, Dementia Care January 4, 2014 Maximizing Independence at Home (MIND) Objectives To assess whether a dementia care coordination intervention delays time to transition from home and reduces unmet needs in elders with memory disorders. Design 18-month randomized controlled trial of 303 community-living elders. Setting 28 postal code areas of Baltimore,... Read More
Care Management/Care Coordination July 1, 2011 The Arkansas Community Connector Program Background: Identifying people at risk of entering nursing homes and connecting them with the home and community-based services they need could reduce long-term care spending. Design: The authors used a longitudinal, quasi-experimental research design that used propensity score match... Read More
Home care April 1, 2013 Personal Care and Homemaking programs This study of the Area Agency on Aging 1-B Personal Care and Homemaking programs documented exceptional dedication, quality, value and outcomes: The majority of home care workers donate extra personal time and resources to consumers.  24/7 access to home care agencies helps preven... Read More
Transportation April 22, 2022 Non-Emergency Medical Transportation Introduction Transportation is an important social determinant of health. We conducted a systematic review of the associations on health and health care utilization of interventions aimed at reducing barriers to non-emergency transportation and non-medical transportation. Methods We ... Read More
Home Modification August 28, 2021 Home Usability Program Background Community participation has become a key outcome measure for people with disabilities. This has resulted in a shift in researchers focus from the individual to the environment. However, research has focused primarily on participation barriers in the community with limited re... Read More
Disease Management February 12, 2016 Living Well with a Disability Approximately 56.7 million persons in the United States have functional impairments that can lead to disability. As a group, persons with disabilities show disparities in measures of overall health when compared with the general population. Much of this can be attributed to secondary co... Read More
Meals and Nutrition July 24, 2017 Supplemental Nutrition Assistance Program (SNAP) Background Although it has long been known that a broad range of factors beyond medical diagnoses affect health and health services use, it has been unclear whether additional income can decrease health service use. We examined whether Supplemental Nutrition Assistance Program (SNAP) r... Read More
Care Management/Care Coordination March 25, 2021 The Right Care, Right Place, Right Time Project: Health-Related Supports in Senior Housing Objective To test the impact of placing a wellness team (nurse and social worker) in senior housing on ambulance transfers and visits to emergency departments over 18 months. Data sources/study setting Intervention sites included seven Boston-area buildings, with five buildings at co... Read More
Care Management/Care Coordination May 31, 2021 Community Care Connections Program Background Integration of social services in health care delivery is increasingly recognized as a potential strategy for improving health and reducing the use of acute care services. Collaborative models that provide older adults with case management, linkages to social services, and a... Read More
Care Management/Care Coordination May 5, 2015 Social Work Care Coordination Abstract This study assessed how a social work–led care coordination intervention would reduce the within-30-day hospital readmission rate among moderate- and high-risk patients age 50 years or older. Authors ran a randomized controlled trial to determine whether there was a significan... Read More
Care Management/Care Coordination, Caregiving, Dementia Care October 16, 2019 Partners in Dementia Care Background and Objectives Numerous non-pharmacological programs for family caregivers and persons with dementia (PWDs) have been found efficacious in randomized controlled trials. Few programs have been tested in translation studies that assess feasibility and outcomes in less-controll... Read More
Fall Prevention/Mobility, Meals and Nutrition August 6, 2015 Home-Delivered Meals and Provision of Vitamin D Objectives To assess the feasibility of a vitamin D intervention delivered through a Meals-on-Wheels (MOW) program to improve 25-hydroxyvitamin D (25(OH)D) concentrations and reduce falls in homebound older adults. Design Single-blind, cluster randomized trial. Setting MOW, Forsy... Read More
Meals and Nutrition October 10, 2013 Home-Delivered Meals Abstract Programs that help older adults live independently in the community can also deliver net savings to states on the costs of long-term supports and services. We estimate that if all states had increased by 1 percent the number of adults age sixty-five or older who received h... Read More
Caregiving, Dementia Care August 19, 2019 REACH-TX Background and Objectives Family caregiving interventions have been proven efficacious at reducing dementia caregiver’s stress and burden, yet translation of evidence-based interventions into community-based support service programs requires modification to the original intervention pr... Read More
Care Management/Care Coordination, Medication Management June 6, 2021 HomeMeds and MedSafety Scan Objectives  Both social and medical factors can negatively affect health outcomes, especially in vulnerable populations. To address these 2 types of factors in a postdischarge population, 2 nonprofit organizations collaborated to combine their novel decision support programs and addres... Read More
Care Management/Care Coordination March 25, 2021 Health-Related Supports in Senior Housing Objectives To test the impact of placing a wellness team (nurse and social worker) in senior housing on ambulance transfers and visits to emergency departments over 18 months. Data sources/study setting Intervention sites included seven Boston-area buildings, with five bu... Read More
Home Modification, Social Engagement January 24, 2019 Seniors Optimizing Community Integration to Advance Better Living with ESRD (SOCIABLE) Rationale & Objective Older adults with end-stage kidney disease have increased morbidity, fatigue, and decreased physical function, which can inhibit self-care and social engagement. We pilot tested a home-based program to improve physical and social functioning of low socioec... Read More
Meals and Nutrition May 18, 2011 Home-Delivered Meals It is critical to use convincing research methodology to demonstrate the benefits of nutrition assistance programs targeted to vulnerable older adults. We examined the impact of Older Americans Act Nutrition Program (OAANP) participation on food security in participants and waitlisted p... Read More
Home Modification January 30, 2015 Community Aging in Place, Advancing Better Living for Elders (CAPABLE) Abstract Current medical models frequently overlook functional limitations and the home environment even though they partially determine healthcare usage and quality of life. The Centers for Medicare and Medicaid Services (CMS) Innovation Center funds projects that have potential to af... Read More