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
- Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- People with Serious Illness
- Medicare
- Medicaid
- Medicare / Medicaid
- Commercial
- 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
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.
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.
Guided Care
- Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- People with Serious Illness
- Medicare
- Medicaid
- Medicare / Medicaid
- Commercial
- 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
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.
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.
Guided Care
- Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- People with Serious Illness
- Medicare
- Medicaid
- Medicare / Medicaid
- Commercial
- 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
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.
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.
Guided Care
- Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- People with Serious Illness
- Medicare
- Medicaid
- Medicare / Medicaid
- Commercial
- 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
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.
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.
Guided Care
- Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- People with Serious Illness
- Medicare
- Medicaid
- Medicare / Medicaid
- Commercial
- 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
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.
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.
Hospital at Home
- Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- People with Serious Illness
- Medicare
- Medicaid
- Medicare / Medicaid
- Commercial
- 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
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).
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.
Hospital at Home
- Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- People with Serious Illness
- Medicare
- Medicaid
- Medicare / Medicaid
- Commercial
- 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
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).
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.
Hospital at Home
- Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- People with Serious Illness
- Medicare
- Medicaid
- Medicare / Medicaid
- Commercial
- 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
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).
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.
Hospital at Home
- Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- People with Serious Illness
- Medicare
- Medicaid
- Medicare / Medicaid
- Commercial
- 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
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).
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.
Hospital at Home
- Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- People with Serious Illness
- Medicare
- Medicaid
- Medicare / Medicaid
- Commercial
- 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
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).
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.