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.
Narrow by:
Homeless Patient Aligned Care Team (H-PACT)
US Department of Veterans AffairsCleveland, OHTarget Population: - People with Multiple Chronic Conditions
Insurance: - Veterans Administration
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: H-PACT is replicated across sixty-five Veterans Administration health centers across the country.
Outcome Notes: A number of detailed studies have been conducted, and found lower costs and utilization were associated with the program.
Point of Contact: Erin Johnson, Management Analyst (Program Manager)401-480-3373Erin.Johnson4@va.gov
Homeless Patient Aligned Care Team (H-PACT)
US Department of Veterans AffairsPrescott, AZTarget Population: - People with Multiple Chronic Conditions
Insurance: - Veterans Administration
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: H-PACT is replicated across sixty-five Veterans Administration health centers across the country.
Outcome Notes: A number of detailed studies have been conducted, and found lower costs and utilization were associated with the program.
Point of Contact: Erin Johnson, Management Analyst (Program Manager)401-480-3373Erin.Johnson4@va.gov
Homeless Patient Aligned Care Team (H-PACT)
US Department of Veterans AffairsDetroit, MITarget Population: - People with Multiple Chronic Conditions
Insurance: - Veterans Administration
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: H-PACT is replicated across sixty-five Veterans Administration health centers across the country.
Outcome Notes: A number of detailed studies have been conducted, and found lower costs and utilization were associated with the program.
Point of Contact: Erin Johnson, Management Analyst (Program Manager)401-480-3373Erin.Johnson4@va.gov
Homeless Patient Aligned Care Team (H-PACT)
US Department of Veterans AffairsProvidence, RITarget Population: - People with Multiple Chronic Conditions
Insurance: - Veterans Administration
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: H-PACT is replicated across sixty-five Veterans Administration health centers across the country.
Outcome Notes: A number of detailed studies have been conducted, and found lower costs and utilization were associated with the program.
Point of Contact: Erin Johnson, Management Analyst (Program Manager)401-480-3373Erin.Johnson4@va.gov
Homeless Patient Aligned Care Team (H-PACT)
US Department of Veterans AffairsDurham, NCTarget Population: - People with Multiple Chronic Conditions
Insurance: - Veterans Administration
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: H-PACT is replicated across sixty-five Veterans Administration health centers across the country.
Outcome Notes: A number of detailed studies have been conducted, and found lower costs and utilization were associated with the program.
Point of Contact: Erin Johnson, Management Analyst (Program Manager)401-480-3373Erin.Johnson4@va.gov
Homeless Patient Aligned Care Team (H-PACT)
US Department of Veterans AffairsRaleigh, NCTarget Population: - People with Multiple Chronic Conditions
Insurance: - Veterans Administration
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: H-PACT is replicated across sixty-five Veterans Administration health centers across the country.
Outcome Notes: A number of detailed studies have been conducted, and found lower costs and utilization were associated with the program.
Point of Contact: Erin Johnson, Management Analyst (Program Manager)401-480-3373Erin.Johnson4@va.gov
Homeless Patient Aligned Care Team (H-PACT)
US Department of Veterans AffairsElizabeth, NJTarget Population: - People with Multiple Chronic Conditions
Insurance: - Veterans Administration
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: H-PACT is replicated across sixty-five Veterans Administration health centers across the country.
Outcome Notes: A number of detailed studies have been conducted, and found lower costs and utilization were associated with the program.
Point of Contact: Erin Johnson, Management Analyst (Program Manager)401-480-3373Erin.Johnson4@va.gov
Homeless Patient Aligned Care Team (H-PACT)
US Department of Veterans AffairsSacramento, CATarget Population: - People with Multiple Chronic Conditions
Insurance: - Veterans Administration
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: H-PACT is replicated across sixty-five Veterans Administration health centers across the country.
Outcome Notes: A number of detailed studies have been conducted, and found lower costs and utilization were associated with the program.
Point of Contact: Erin Johnson, Management Analyst (Program Manager)401-480-3373Erin.Johnson4@va.gov
Homeless Patient Aligned Care Team (H-PACT)
US Department of Veterans AffairsEwa Beach, HITarget Population: - People with Multiple Chronic Conditions
Insurance: - Veterans Administration
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: H-PACT is replicated across sixty-five Veterans Administration health centers across the country.
Outcome Notes: A number of detailed studies have been conducted, and found lower costs and utilization were associated with the program.
Point of Contact: Erin Johnson, Management Analyst (Program Manager)401-480-3373Erin.Johnson4@va.gov
Homeless Patient Aligned Care Team (H-PACT)
US Department of Veterans AffairsSalt Lake City, UTTarget Population: - People with Multiple Chronic Conditions
Insurance: - Veterans Administration
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: H-PACT is replicated across sixty-five Veterans Administration health centers across the country.
Outcome Notes: A number of detailed studies have been conducted, and found lower costs and utilization were associated with the program.
Point of Contact: Erin Johnson, Management Analyst (Program Manager)401-480-3373Erin.Johnson4@va.gov
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.
Narrow by:
Homeless Patient Aligned Care Team (H-PACT)
- People with Multiple Chronic Conditions
- Veterans Administration
- 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
H-PACT is replicated across sixty-five Veterans Administration health centers across the country.
A number of detailed studies have been conducted, and found lower costs and utilization were associated with the program.
Homeless Patient Aligned Care Team (H-PACT)
- People with Multiple Chronic Conditions
- Veterans Administration
- 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
H-PACT is replicated across sixty-five Veterans Administration health centers across the country.
A number of detailed studies have been conducted, and found lower costs and utilization were associated with the program.
Homeless Patient Aligned Care Team (H-PACT)
- People with Multiple Chronic Conditions
- Veterans Administration
- 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
H-PACT is replicated across sixty-five Veterans Administration health centers across the country.
A number of detailed studies have been conducted, and found lower costs and utilization were associated with the program.
Homeless Patient Aligned Care Team (H-PACT)
- People with Multiple Chronic Conditions
- Veterans Administration
- 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
H-PACT is replicated across sixty-five Veterans Administration health centers across the country.
A number of detailed studies have been conducted, and found lower costs and utilization were associated with the program.
Homeless Patient Aligned Care Team (H-PACT)
- People with Multiple Chronic Conditions
- Veterans Administration
- 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
H-PACT is replicated across sixty-five Veterans Administration health centers across the country.
A number of detailed studies have been conducted, and found lower costs and utilization were associated with the program.
Homeless Patient Aligned Care Team (H-PACT)
- People with Multiple Chronic Conditions
- Veterans Administration
- 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
H-PACT is replicated across sixty-five Veterans Administration health centers across the country.
A number of detailed studies have been conducted, and found lower costs and utilization were associated with the program.
Homeless Patient Aligned Care Team (H-PACT)
- People with Multiple Chronic Conditions
- Veterans Administration
- 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
H-PACT is replicated across sixty-five Veterans Administration health centers across the country.
A number of detailed studies have been conducted, and found lower costs and utilization were associated with the program.
Homeless Patient Aligned Care Team (H-PACT)
- People with Multiple Chronic Conditions
- Veterans Administration
- 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
H-PACT is replicated across sixty-five Veterans Administration health centers across the country.
A number of detailed studies have been conducted, and found lower costs and utilization were associated with the program.
Homeless Patient Aligned Care Team (H-PACT)
- People with Multiple Chronic Conditions
- Veterans Administration
- 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
H-PACT is replicated across sixty-five Veterans Administration health centers across the country.
A number of detailed studies have been conducted, and found lower costs and utilization were associated with the program.
Homeless Patient Aligned Care Team (H-PACT)
- People with Multiple Chronic Conditions
- Veterans Administration
- 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
H-PACT is replicated across sixty-five Veterans Administration health centers across the country.
A number of detailed studies have been conducted, and found lower costs and utilization were associated with the program.