Use the filters below to learn about programs across the country that are working to care for people with complex medical, behavioral health, and social needs. Learn more about how this map was developed. The Playbook also welcomes submissions from the field — learn how to submit your program.

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Guided Care

Johns Hopkins University
Boston, MA
Guided Care
Target Population:
  • Adults Under 65 with Disabilities
  • Frail Older Adults
  • People with Multiple Chronic Conditions
  • People with Serious Illness
Insurance:
  • Medicare
  • Medicaid
  • Medicare / Medicaid
  • Commercial
Care Program Elements:
  • Individualized care plan
  • Ongoing care plan review
  • Interdisciplinary care team
  • Active care coordination
  • Assesses behavioral health care needs and coordinates services
  • Addresses social determinants of health
  • One lead point of contact
  • Shares information across care team/health providers
  • Education for providers and patient
Replicated Sites:

Guided Care has been replicated in six cities (Baltimore, MD; Boston, MA; Jamestown, NY; Lynchburg, VA; Midland, MI; and New Bern, NC) and within two health plans, TUFTS Associated HMO and the Kaiser Foundation Health Plan.

Outcome Notes:

Studies and evaluations have shown increased enrollee reported ratings of the quality of care, reductions in the use of home care, and increased physician satisfaction of family communication. Some studies showed substantial impact in one participating provider group.

Point of Contact:
Cynthia Boyd, Professor of Medicine
410-550-8676
cyboyd@jhmi.edu

Guided Care

Johns Hopkins University
Jamestown, NY
Guided Care
Target Population:
  • Adults Under 65 with Disabilities
  • Frail Older Adults
  • People with Multiple Chronic Conditions
  • People with Serious Illness
Insurance:
  • Medicare
  • Medicaid
  • Medicare / Medicaid
  • Commercial
Care Program Elements:
  • Individualized care plan
  • Ongoing care plan review
  • Interdisciplinary care team
  • Active care coordination
  • Assesses behavioral health care needs and coordinates services
  • Addresses social determinants of health
  • One lead point of contact
  • Shares information across care team/health providers
  • Education for providers and patient
Replicated Sites:

Guided Care has been replicated in six cities (Baltimore, MD; Boston, MA; Jamestown, NY; Lynchburg, VA; Midland, MI; and New Bern, NC) and within two health plans, TUFTS Associated HMO and the Kaiser Foundation Health Plan.

Outcome Notes:

Studies and evaluations have shown increased enrollee reported ratings of the quality of care, reductions in the use of home care, and increased physician satisfaction of family communication. Some studies showed substantial impact in one participating provider group.

Point of Contact:
Cynthia Boyd, Professor of Medicine
410-550-8676
cyboyd@jhmi.edu

Guided Care

Johns Hopkins University
Lynchburg, VA
Guided Care
Target Population:
  • Adults Under 65 with Disabilities
  • Frail Older Adults
  • People with Multiple Chronic Conditions
  • People with Serious Illness
Insurance:
  • Medicare
  • Medicaid
  • Medicare / Medicaid
  • Commercial
Care Program Elements:
  • Individualized care plan
  • Ongoing care plan review
  • Interdisciplinary care team
  • Active care coordination
  • Assesses behavioral health care needs and coordinates services
  • Addresses social determinants of health
  • One lead point of contact
  • Shares information across care team/health providers
  • Education for providers and patient
Replicated Sites:

Guided Care has been replicated in six cities (Baltimore, MD; Boston, MA; Jamestown, NY; Lynchburg, VA; Midland, MI; and New Bern, NC) and within two health plans, TUFTS Associated HMO and the Kaiser Foundation Health Plan.

Outcome Notes:

Studies and evaluations have shown increased enrollee reported ratings of the quality of care, reductions in the use of home care, and increased physician satisfaction of family communication. Some studies showed substantial impact in one participating provider group.

Point of Contact:
Cynthia Boyd, Professor of Medicine
410-550-8676
cyboyd@jhmi.edu

Guided Care

Johns Hopkins University
Midland, MI
Guided Care
Target Population:
  • Adults Under 65 with Disabilities
  • Frail Older Adults
  • People with Multiple Chronic Conditions
  • People with Serious Illness
Insurance:
  • Medicare
  • Medicaid
  • Medicare / Medicaid
  • Commercial
Care Program Elements:
  • Individualized care plan
  • Ongoing care plan review
  • Interdisciplinary care team
  • Active care coordination
  • Assesses behavioral health care needs and coordinates services
  • Addresses social determinants of health
  • One lead point of contact
  • Shares information across care team/health providers
  • Education for providers and patient
Replicated Sites:

Guided Care has been replicated in six cities (Baltimore, MD; Boston, MA; Jamestown, NY; Lynchburg, VA; Midland, MI; and New Bern, NC) and within two health plans, TUFTS Associated HMO and the Kaiser Foundation Health Plan.

Outcome Notes:

Studies and evaluations have shown increased enrollee reported ratings of the quality of care, reductions in the use of home care, and increased physician satisfaction of family communication. Some studies showed substantial impact in one participating provider group.

Point of Contact:
Cynthia Boyd, Professor of Medicine
410-550-8676
cyboyd@jhmi.edu

Guided Care

Johns Hopkins University
New Bern, NC
Guided Care
Target Population:
  • Adults Under 65 with Disabilities
  • Frail Older Adults
  • People with Multiple Chronic Conditions
  • People with Serious Illness
Insurance:
  • Medicare
  • Medicaid
  • Medicare / Medicaid
  • Commercial
Care Program Elements:
  • Individualized care plan
  • Ongoing care plan review
  • Interdisciplinary care team
  • Active care coordination
  • Assesses behavioral health care needs and coordinates services
  • Addresses social determinants of health
  • One lead point of contact
  • Shares information across care team/health providers
  • Education for providers and patient
Replicated Sites:

Guided Care has been replicated in six cities (Baltimore, MD; Boston, MA; Jamestown, NY; Lynchburg, VA; Midland, MI; and New Bern, NC) and within two health plans, TUFTS Associated HMO and the Kaiser Foundation Health Plan.

Outcome Notes:

Studies and evaluations have shown increased enrollee reported ratings of the quality of care, reductions in the use of home care, and increased physician satisfaction of family communication. Some studies showed substantial impact in one participating provider group.

Point of Contact:
Cynthia Boyd, Professor of Medicine
410-550-8676
cyboyd@jhmi.edu

Hospital at Home

Johns Hopkins University School of Medicine
New York, NY
Hospital at Home
Target Population:
  • Adults Under 65 with Disabilities
  • Frail Older Adults
  • People with Multiple Chronic Conditions
  • People with Serious Illness
Insurance:
  • Medicare
  • Medicaid
  • Medicare / Medicaid
  • Commercial
Care Program Elements:
  • Individualized care plan
  • Ongoing care plan review
  • Interdisciplinary care team
  • Active care coordination
  • Assesses behavioral health care needs and coordinates services
  • Addresses social determinants of health
  • One lead point of contact
  • Shares information across care team/health providers
  • Education for providers and patient
  • Engages in performance measurement/quality
Replicated Sites:

The Hospital at Home program has been replicated in 12 sites around the country (Albuquerque, NM; Baltimore, MD; Boise, ID; Boston, MA; Cincinnati, OH; Columbus, OH; Honolulu, HI; Los Angeles, CA; New Orleans, LA; New York, NY; Philadelphia, PA; and Portland, OR).

Outcome Notes:

A variety of studies have shown the program has produced results, such as: lower costs; reduced complications; better functional status; better patient and caregiver experience; and lower caregiver stress.

Point of Contact:
Bruce Leff, Professor of Medicine
410-550-2654
bleff@jhmi.edu

Hospital at Home

Johns Hopkins University School of Medicine
Philadelphia, PA
Hospital at Home
Target Population:
  • Adults Under 65 with Disabilities
  • Frail Older Adults
  • People with Multiple Chronic Conditions
  • People with Serious Illness
Insurance:
  • Medicare
  • Medicaid
  • Medicare / Medicaid
  • Commercial
Care Program Elements:
  • Individualized care plan
  • Ongoing care plan review
  • Interdisciplinary care team
  • Active care coordination
  • Assesses behavioral health care needs and coordinates services
  • Addresses social determinants of health
  • One lead point of contact
  • Shares information across care team/health providers
  • Education for providers and patient
  • Engages in performance measurement/quality
Replicated Sites:

The Hospital at Home program has been replicated in 12 sites around the country (Albuquerque, NM; Baltimore, MD; Boise, ID; Boston, MA; Cincinnati, OH; Columbus, OH; Honolulu, HI; Los Angeles, CA; New Orleans, LA; New York, NY; Philadelphia, PA; and Portland, OR).

Outcome Notes:

A variety of studies have shown the program has produced results, such as: lower costs; reduced complications; better functional status; better patient and caregiver experience; and lower caregiver stress.

Point of Contact:
Bruce Leff, Professor of Medicine
410-550-2654
bleff@jhmi.edu

Hospital at Home

Johns Hopkins University School of Medicine
Portland, OR
Hospital at Home
Target Population:
  • Adults Under 65 with Disabilities
  • Frail Older Adults
  • People with Multiple Chronic Conditions
  • People with Serious Illness
Insurance:
  • Medicare
  • Medicaid
  • Medicare / Medicaid
  • Commercial
Care Program Elements:
  • Individualized care plan
  • Ongoing care plan review
  • Interdisciplinary care team
  • Active care coordination
  • Assesses behavioral health care needs and coordinates services
  • Addresses social determinants of health
  • One lead point of contact
  • Shares information across care team/health providers
  • Education for providers and patient
  • Engages in performance measurement/quality
Replicated Sites:

The Hospital at Home program has been replicated in 12 sites around the country (Albuquerque, NM; Baltimore, MD; Boise, ID; Boston, MA; Cincinnati, OH; Columbus, OH; Honolulu, HI; Los Angeles, CA; New Orleans, LA; New York, NY; Philadelphia, PA; and Portland, OR).

Outcome Notes:

A variety of studies have shown the program has produced results, such as: lower costs; reduced complications; better functional status; better patient and caregiver experience; and lower caregiver stress.

Point of Contact:
Bruce Leff, Professor of Medicine
410-550-2654
bleff@jhmi.edu

Hospital at Home

Johns Hopkins University School of Medicine
Albuquerque, NM
Hospital at Home
Target Population:
  • Adults Under 65 with Disabilities
  • Frail Older Adults
  • People with Multiple Chronic Conditions
  • People with Serious Illness
Insurance:
  • Medicare
  • Medicaid
  • Medicare / Medicaid
  • Commercial
Care Program Elements:
  • Individualized care plan
  • Ongoing care plan review
  • Interdisciplinary care team
  • Active care coordination
  • Assesses behavioral health care needs and coordinates services
  • Addresses social determinants of health
  • One lead point of contact
  • Shares information across care team/health providers
  • Education for providers and patient
  • Engages in performance measurement/quality
Replicated Sites:

The Hospital at Home program has been replicated in 12 sites around the country (Albuquerque, NM; Baltimore, MD; Boise, ID; Boston, MA; Cincinnati, OH; Columbus, OH; Honolulu, HI; Los Angeles, CA; New Orleans, LA; New York, NY; Philadelphia, PA; and Portland, OR).

Outcome Notes:

A variety of studies have shown the program has produced results, such as: lower costs; reduced complications; better functional status; better patient and caregiver experience; and lower caregiver stress.

Point of Contact:
Bruce Leff, Professor of Medicine
410-550-2654
bleff@jhmi.edu

Hospital at Home

Johns Hopkins University School of Medicine
Baltimore, MD
Hospital at Home
Target Population:
  • Adults Under 65 with Disabilities
  • Frail Older Adults
  • People with Multiple Chronic Conditions
  • People with Serious Illness
Insurance:
  • Medicare
  • Medicaid
  • Medicare / Medicaid
  • Commercial
Care Program Elements:
  • Individualized care plan
  • Ongoing care plan review
  • Interdisciplinary care team
  • Active care coordination
  • Assesses behavioral health care needs and coordinates services
  • Addresses social determinants of health
  • One lead point of contact
  • Shares information across care team/health providers
  • Education for providers and patient
  • Engages in performance measurement/quality
Replicated Sites:

The Hospital at Home program has been replicated in 12 sites around the country (Albuquerque, NM; Baltimore, MD; Boise, ID; Boston, MA; Cincinnati, OH; Columbus, OH; Honolulu, HI; Los Angeles, CA; New Orleans, LA; New York, NY; Philadelphia, PA; and Portland, OR).

Outcome Notes:

A variety of studies have shown the program has produced results, such as: lower costs; reduced complications; better functional status; better patient and caregiver experience; and lower caregiver stress.

Point of Contact:
Bruce Leff, Professor of Medicine
410-550-2654
bleff@jhmi.edu