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:
Care Management Plus
Oregon Health & Science UniversityWenatchee, WATarget Population: - 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: Care Management Plus has been replicated in 400 sites in twenty-one states (AK, AZ, CA, GA, ID, IL, IN, KS, LA, MA, ME, MI, MN, NM, NV, NY, OH, OR, TX, UT, WA)
Outcome Notes: A controlled trial of the model showed lowered hospitalizations, and for patients with diabetes, lower mortality.
Point of Contact: David Dorr , Professor and Vice Chair 503-349-1633dorrd@ohsu.edu
Integrated Care Management Program (iCMP)
Partners HealthcareBoston, MATarget 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 Integrated Care Management Program has not been replicated.
Outcome Notes: Peer reviewed study found reduced ED utilization, decrease in hospitalization, and lower overall costs.
Point of Contact: Eric Weil, CMO primary care617-480-6634eweil@mgh.harvard.edu
Patient Care Intervention Center and Unified Care Continuum Platform
Patient Care Intervention CenterDallas, TXTarget Population: - Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- People with Serious Illness
Insurance: - Medicare
- Medicaid
- Medicare / Medicaid
- Uninsured
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 Patient Care Intervention Center's model is replicated in Camden, NJ, and two sites -- Dallas and Houston -- in Texas.
Outcome Notes: Early results suggest decreases in ED utilization and costs. Research is ongoing to learn more.
Point of Contact: David Buck, MD, President713-798-8635dbuck@pcictx.org
Patient Care Intervention Center and Unified Care Continuum Platform
Patient Care Intervention CenterHouston, TXTarget Population: - Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- People with Serious Illness
Insurance: - Medicare
- Medicaid
- Medicare / Medicaid
- Uninsured
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 Patient Care Intervention Center's model is replicated in Camden, NJ, and two sites -- Dallas and Houston -- in Texas.
Outcome Notes: Early results suggest decreases in ED utilization and costs. Research is ongoing to learn more.
Point of Contact: David Buck, MD, President713-798-8635dbuck@pcictx.org
Patient Care Intervention Center and Unified Care Continuum Platform
Patient Care Intervention CenterCamden, NJTarget Population: - Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- People with Serious Illness
Insurance: - Medicare
- Medicaid
- Medicare / Medicaid
- Uninsured
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 Patient Care Intervention Center's model is replicated in Camden, NJ, and two sites -- Dallas and Houston -- in Texas.
Outcome Notes: Early results suggest decreases in ED utilization and costs. Research is ongoing to learn more.
Point of Contact: David Buck, MD, President713-798-8635dbuck@pcictx.org
Whole Person Care - High Users of Multiple Systems (HUMS)
San Francisco Department of Public HealthSan Francisco, CATarget Population: - Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- People with Serious Illness
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
- 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 High Users of Multiple Systems program has not been replicated.
Outcome Notes: Evaluation of results is underway.
Point of Contact: Maria X Martinez, Director, Whole Person Care415-554-2877maria.x.martinez@sfdph.org
Community Based Care Management
San Francisco Health PlanSan Francisco, CATarget Population: - Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- People with Serious Illness
Insurance: - Medicaid
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: Community Based Care Management has not been replicated.
Outcome Notes: None yet publicly available
Point of Contact: Courtney Gray, Director of Care Management 415-615-4213cgray@sfhp.org
Care Coordination Program
Santa Rosa Community HealthSanta Rosa, CATarget Population: - Adults Under 65 with Disabilities
- People with Multiple Chronic Conditions
- People with Serious Illness
Insurance: - Medicaid
- Medicare / Medicaid
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: Santa Rosa Community Health's Care Coordination Program has not been replicated.
Outcome Notes: None yet
Point of Contact: Barbara Scherrer , Director of Innovation 701-303-3600barbs@srhealth.org
Stanford Coordinated Care (SCC)
Stanford Health Care Palo Alto, CATarget Population: - Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- People with Serious Illness
Insurance: - Medicare
- 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: Stanford Coordinated Care has not been replicated.
Outcome Notes: Formal evaluation is underway.
Point of Contact: Coleen Travers , LCSW650-736-2613ctravers@stanfordhealthcare.org
Complex Care Team / Community Hospital Acceleration, Revitalization, & Transformation Investment Program
UMassMemorial - Marlborough HospitalMarlborough, MATarget Population: - Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- People with Serious Illness
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
- One lead point of contact
- Shares information across care team/health providers
- Education for providers and patient
- Engages in performance measurement/quality
Replicated Sites: UMass Memorial's Complex Care Teams operate at twenty-two locations nearby Marlborough, Massachusetts.
Outcome Notes: Early results indicate that the CHART program resulted in a total utilization reduction difference of 16% for patients enrolled in the program.
Point of Contact: Irene Hadley, Director, Care Coordination, CHART Project MGR508-486-5620irene.hadley@umassmemorial.org
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:
Care Management Plus
- 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
Care Management Plus has been replicated in 400 sites in twenty-one states (AK, AZ, CA, GA, ID, IL, IN, KS, LA, MA, ME, MI, MN, NM, NV, NY, OH, OR, TX, UT, WA)
A controlled trial of the model showed lowered hospitalizations, and for patients with diabetes, lower mortality.
Integrated Care Management Program (iCMP)
- 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 Integrated Care Management Program has not been replicated.
Peer reviewed study found reduced ED utilization, decrease in hospitalization, and lower overall costs.
Patient Care Intervention Center and Unified Care Continuum Platform
- Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- People with Serious Illness
- Medicare
- Medicaid
- Medicare / Medicaid
- Uninsured
- 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 Patient Care Intervention Center's model is replicated in Camden, NJ, and two sites -- Dallas and Houston -- in Texas.
Early results suggest decreases in ED utilization and costs. Research is ongoing to learn more.
Patient Care Intervention Center and Unified Care Continuum Platform
- Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- People with Serious Illness
- Medicare
- Medicaid
- Medicare / Medicaid
- Uninsured
- 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 Patient Care Intervention Center's model is replicated in Camden, NJ, and two sites -- Dallas and Houston -- in Texas.
Early results suggest decreases in ED utilization and costs. Research is ongoing to learn more.
Patient Care Intervention Center and Unified Care Continuum Platform
- Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- People with Serious Illness
- Medicare
- Medicaid
- Medicare / Medicaid
- Uninsured
- 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 Patient Care Intervention Center's model is replicated in Camden, NJ, and two sites -- Dallas and Houston -- in Texas.
Early results suggest decreases in ED utilization and costs. Research is ongoing to learn more.
Whole Person Care - High Users of Multiple Systems (HUMS)
- Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- People with Serious Illness
- 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
- One lead point of contact
- Shares information across care team/health providers
- Education for providers and patient
- Engages in performance measurement/quality
The High Users of Multiple Systems program has not been replicated.
Evaluation of results is underway.
Community Based Care Management
- Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- People with Serious Illness
- Medicaid
- 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
Community Based Care Management has not been replicated.
None yet publicly available
Care Coordination Program
- Adults Under 65 with Disabilities
- People with Multiple Chronic Conditions
- People with Serious Illness
- Medicaid
- Medicare / Medicaid
- 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
Santa Rosa Community Health's Care Coordination Program has not been replicated.
None yet
Stanford Coordinated Care (SCC)
- Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- People with Serious Illness
- Medicare
- 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
Stanford Coordinated Care has not been replicated.
Formal evaluation is underway.
Complex Care Team / Community Hospital Acceleration, Revitalization, & Transformation Investment Program
- Adults Under 65 with Disabilities
- Frail Older Adults
- People with Multiple Chronic Conditions
- People with Serious Illness
- 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
- One lead point of contact
- Shares information across care team/health providers
- Education for providers and patient
- Engages in performance measurement/quality
UMass Memorial's Complex Care Teams operate at twenty-two locations nearby Marlborough, Massachusetts.
Early results indicate that the CHART program resulted in a total utilization reduction difference of 16% for patients enrolled in the program.