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:
Community Aging in Place -Advancing Better Living for Elders (CAPABLE)
Johns Hopkins University School of Nursing CAPABLE programDenver, COTarget Population: - Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
Insurance: - Medicare
- Medicaid
- Medicare / Medicaid
- Uninsured
- 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
- Shares information across care team/health providers
- Education for providers and patient
Replicated Sites: The CAPABLE program has been replicated in seventeen cities around the country.
Outcome Notes: Studies have shown improved ability to perform activities of daily living, and reduced ED and hospital utilization, and reductions in cost.
Point of Contact: Sarah Szanton, Professor410-502-2605sszanto1@jhu.edu
Community Aging in Place -Advancing Better Living for Elders (CAPABLE)
Johns Hopkins University School of Nursing CAPABLE programDetroit, MITarget Population: - Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
Insurance: - Medicare
- Medicaid
- Medicare / Medicaid
- Uninsured
- 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
- Shares information across care team/health providers
- Education for providers and patient
Replicated Sites: The CAPABLE program has been replicated in seventeen cities around the country.
Outcome Notes: Studies have shown improved ability to perform activities of daily living, and reduced ED and hospital utilization, and reductions in cost.
Point of Contact: Sarah Szanton, Professor410-502-2605sszanto1@jhu.edu
Community Aging in Place -Advancing Better Living for Elders (CAPABLE)
Johns Hopkins University School of Nursing CAPABLE programFlint, MITarget Population: - Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
Insurance: - Medicare
- Medicaid
- Medicare / Medicaid
- Uninsured
- 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
- Shares information across care team/health providers
- Education for providers and patient
Replicated Sites: The CAPABLE program has been replicated in seventeen cities around the country.
Outcome Notes: Studies have shown improved ability to perform activities of daily living, and reduced ED and hospital utilization, and reductions in cost.
Point of Contact: Sarah Szanton, Professor410-502-2605sszanto1@jhu.edu
Community Aging in Place -Advancing Better Living for Elders (CAPABLE)
Johns Hopkins University School of Nursing CAPABLE programFort Fairfield, METarget Population: - Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
Insurance: - Medicare
- Medicaid
- Medicare / Medicaid
- Uninsured
- 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
- Shares information across care team/health providers
- Education for providers and patient
Replicated Sites: The CAPABLE program has been replicated in seventeen cities around the country.
Outcome Notes: Studies have shown improved ability to perform activities of daily living, and reduced ED and hospital utilization, and reductions in cost.
Point of Contact: Sarah Szanton, Professor410-502-2605sszanto1@jhu.edu
Community Aging in Place -Advancing Better Living for Elders (CAPABLE)
Johns Hopkins University School of Nursing CAPABLE programGrand Rapids, MITarget Population: - Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
Insurance: - Medicare
- Medicaid
- Medicare / Medicaid
- Uninsured
- 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
- Shares information across care team/health providers
- Education for providers and patient
Replicated Sites: The CAPABLE program has been replicated in seventeen cities around the country.
Outcome Notes: Studies have shown improved ability to perform activities of daily living, and reduced ED and hospital utilization, and reductions in cost.
Point of Contact: Sarah Szanton, Professor410-502-2605sszanto1@jhu.edu
Community Aging in Place -Advancing Better Living for Elders (CAPABLE)
Johns Hopkins University School of Nursing CAPABLE programGreensboro, NCTarget Population: - Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
Insurance: - Medicare
- Medicaid
- Medicare / Medicaid
- Uninsured
- 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
- Shares information across care team/health providers
- Education for providers and patient
Replicated Sites: The CAPABLE program has been replicated in seventeen cities around the country.
Outcome Notes: Studies have shown improved ability to perform activities of daily living, and reduced ED and hospital utilization, and reductions in cost.
Point of Contact: Sarah Szanton, Professor410-502-2605sszanto1@jhu.edu
Community Aging in Place -Advancing Better Living for Elders (CAPABLE)
Johns Hopkins University School of Nursing CAPABLE programMuskegon, MITarget Population: - Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
Insurance: - Medicare
- Medicaid
- Medicare / Medicaid
- Uninsured
- 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
- Shares information across care team/health providers
- Education for providers and patient
Replicated Sites: The CAPABLE program has been replicated in seventeen cities around the country.
Outcome Notes: Studies have shown improved ability to perform activities of daily living, and reduced ED and hospital utilization, and reductions in cost.
Point of Contact: Sarah Szanton, Professor410-502-2605sszanto1@jhu.edu
Community Aging in Place -Advancing Better Living for Elders (CAPABLE)
Johns Hopkins University School of Nursing CAPABLE programNew York, NYTarget Population: - Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
Insurance: - Medicare
- Medicaid
- Medicare / Medicaid
- Uninsured
- 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
- Shares information across care team/health providers
- Education for providers and patient
Replicated Sites: The CAPABLE program has been replicated in seventeen cities around the country.
Outcome Notes: Studies have shown improved ability to perform activities of daily living, and reduced ED and hospital utilization, and reductions in cost.
Point of Contact: Sarah Szanton, Professor410-502-2605sszanto1@jhu.edu
Community Aging in Place -Advancing Better Living for Elders (CAPABLE)
Johns Hopkins University School of Nursing CAPABLE programOrono, METarget Population: - Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
Insurance: - Medicare
- Medicaid
- Medicare / Medicaid
- Uninsured
- 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
- Shares information across care team/health providers
- Education for providers and patient
Replicated Sites: The CAPABLE program has been replicated in seventeen cities around the country.
Outcome Notes: Studies have shown improved ability to perform activities of daily living, and reduced ED and hospital utilization, and reductions in cost.
Point of Contact: Sarah Szanton, Professor410-502-2605sszanto1@jhu.edu
Community Aging in Place -Advancing Better Living for Elders (CAPABLE)
Johns Hopkins University School of Nursing CAPABLE programSaginaw, MITarget Population: - Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
Insurance: - Medicare
- Medicaid
- Medicare / Medicaid
- Uninsured
- 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
- Shares information across care team/health providers
- Education for providers and patient
Replicated Sites: The CAPABLE program has been replicated in seventeen cities around the country.
Outcome Notes: Studies have shown improved ability to perform activities of daily living, and reduced ED and hospital utilization, and reductions in cost.
Point of Contact: Sarah Szanton, Professor410-502-2605sszanto1@jhu.edu
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:
Community Aging in Place -Advancing Better Living for Elders (CAPABLE)
- Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- Medicare
- Medicaid
- Medicare / Medicaid
- Uninsured
- 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
- Shares information across care team/health providers
- Education for providers and patient
The CAPABLE program has been replicated in seventeen cities around the country.
Studies have shown improved ability to perform activities of daily living, and reduced ED and hospital utilization, and reductions in cost.
Community Aging in Place -Advancing Better Living for Elders (CAPABLE)
- Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- Medicare
- Medicaid
- Medicare / Medicaid
- Uninsured
- 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
- Shares information across care team/health providers
- Education for providers and patient
The CAPABLE program has been replicated in seventeen cities around the country.
Studies have shown improved ability to perform activities of daily living, and reduced ED and hospital utilization, and reductions in cost.
Community Aging in Place -Advancing Better Living for Elders (CAPABLE)
- Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- Medicare
- Medicaid
- Medicare / Medicaid
- Uninsured
- 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
- Shares information across care team/health providers
- Education for providers and patient
The CAPABLE program has been replicated in seventeen cities around the country.
Studies have shown improved ability to perform activities of daily living, and reduced ED and hospital utilization, and reductions in cost.
Community Aging in Place -Advancing Better Living for Elders (CAPABLE)
- Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- Medicare
- Medicaid
- Medicare / Medicaid
- Uninsured
- 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
- Shares information across care team/health providers
- Education for providers and patient
The CAPABLE program has been replicated in seventeen cities around the country.
Studies have shown improved ability to perform activities of daily living, and reduced ED and hospital utilization, and reductions in cost.
Community Aging in Place -Advancing Better Living for Elders (CAPABLE)
- Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- Medicare
- Medicaid
- Medicare / Medicaid
- Uninsured
- 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
- Shares information across care team/health providers
- Education for providers and patient
The CAPABLE program has been replicated in seventeen cities around the country.
Studies have shown improved ability to perform activities of daily living, and reduced ED and hospital utilization, and reductions in cost.
Community Aging in Place -Advancing Better Living for Elders (CAPABLE)
- Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- Medicare
- Medicaid
- Medicare / Medicaid
- Uninsured
- 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
- Shares information across care team/health providers
- Education for providers and patient
The CAPABLE program has been replicated in seventeen cities around the country.
Studies have shown improved ability to perform activities of daily living, and reduced ED and hospital utilization, and reductions in cost.
Community Aging in Place -Advancing Better Living for Elders (CAPABLE)
- Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- Medicare
- Medicaid
- Medicare / Medicaid
- Uninsured
- 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
- Shares information across care team/health providers
- Education for providers and patient
The CAPABLE program has been replicated in seventeen cities around the country.
Studies have shown improved ability to perform activities of daily living, and reduced ED and hospital utilization, and reductions in cost.
Community Aging in Place -Advancing Better Living for Elders (CAPABLE)
- Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- Medicare
- Medicaid
- Medicare / Medicaid
- Uninsured
- 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
- Shares information across care team/health providers
- Education for providers and patient
The CAPABLE program has been replicated in seventeen cities around the country.
Studies have shown improved ability to perform activities of daily living, and reduced ED and hospital utilization, and reductions in cost.
Community Aging in Place -Advancing Better Living for Elders (CAPABLE)
- Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- Medicare
- Medicaid
- Medicare / Medicaid
- Uninsured
- 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
- Shares information across care team/health providers
- Education for providers and patient
The CAPABLE program has been replicated in seventeen cities around the country.
Studies have shown improved ability to perform activities of daily living, and reduced ED and hospital utilization, and reductions in cost.
Community Aging in Place -Advancing Better Living for Elders (CAPABLE)
- Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- Medicare
- Medicaid
- Medicare / Medicaid
- Uninsured
- 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
- Shares information across care team/health providers
- Education for providers and patient
The CAPABLE program has been replicated in seventeen cities around the country.
Studies have shown improved ability to perform activities of daily living, and reduced ED and hospital utilization, and reductions in cost.