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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Emergency Patient Interdisciplinary Care (EPiC)

University of Illinois Hospital & Health Sciences System
Chicago, IL
Emergency Patient Interdisciplinary Care
Target 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
  • One lead point of contact
  • Shares information across care team/health providers
Replicated Sites:

The Emergency Patient Interdisciplinary Care program has not been replicated.

Outcome Notes:

An evaluation of outcomes is currently underway.

Point of Contact:
Stephen B Brown, Director of Preventive Emergency Medicine
312-996-4859
sbbrown9@uic.edu

The Transitional Care Model (TCM)

University of Pennsylvania School of Nursing
Columbus, OH
Transitional Care Model
Target 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:

The Transitional Care Model is used in 342 locations in forty-six states (AK, AL, AR, AZ, CA, CO, CT, DE, FL, GA, HI, IA, ID, IL, IN, KS, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, NV, NY, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI).

Outcome Notes:

A number of randomized control trials have shown reductions in all-cause readmissions and reduced costs.

Point of Contact:
Karen Hirschman, Associate Professor
215-573-3755
hirschk@nursing.upenn.edu

The Transitional Care Model (TCM)

University of Pennsylvania School of Nursing
Tanana, AK
Transitional Care Model
Target 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:

The Transitional Care Model is used in 342 locations in forty-six states (AK, AL, AR, AZ, CA, CO, CT, DE, FL, GA, HI, IA, ID, IL, IN, KS, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, NV, NY, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI).

Outcome Notes:

A number of randomized control trials have shown reductions in all-cause readmissions and reduced costs.

Point of Contact:
Karen Hirschman, Associate Professor
215-573-3755
hirschk@nursing.upenn.edu

The Transitional Care Model (TCM)

University of Pennsylvania School of Nursing
Oklahoma City, OK
Transitional Care Model
Target 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:

The Transitional Care Model is used in 342 locations in forty-six states (AK, AL, AR, AZ, CA, CO, CT, DE, FL, GA, HI, IA, ID, IL, IN, KS, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, NV, NY, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI).

Outcome Notes:

A number of randomized control trials have shown reductions in all-cause readmissions and reduced costs.

Point of Contact:
Karen Hirschman, Associate Professor
215-573-3755
hirschk@nursing.upenn.edu

The Transitional Care Model (TCM)

University of Pennsylvania School of Nursing
Clanton, AL
Transitional Care Model
Target 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:

The Transitional Care Model is used in 342 locations in forty-six states (AK, AL, AR, AZ, CA, CO, CT, DE, FL, GA, HI, IA, ID, IL, IN, KS, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, NV, NY, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI).

Outcome Notes:

A number of randomized control trials have shown reductions in all-cause readmissions and reduced costs.

Point of Contact:
Karen Hirschman, Associate Professor
215-573-3755
hirschk@nursing.upenn.edu

The Transitional Care Model (TCM)

University of Pennsylvania School of Nursing
Prineville, OR
Transitional Care Model
Target 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:

The Transitional Care Model is used in 342 locations in forty-six states (AK, AL, AR, AZ, CA, CO, CT, DE, FL, GA, HI, IA, ID, IL, IN, KS, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, NV, NY, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI).

Outcome Notes:

A number of randomized control trials have shown reductions in all-cause readmissions and reduced costs.

Point of Contact:
Karen Hirschman, Associate Professor
215-573-3755
hirschk@nursing.upenn.edu

The Transitional Care Model (TCM)

University of Pennsylvania School of Nursing
Little Rock, AR
Transitional Care Model
Target 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:

The Transitional Care Model is used in 342 locations in forty-six states (AK, AL, AR, AZ, CA, CO, CT, DE, FL, GA, HI, IA, ID, IL, IN, KS, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, NV, NY, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI).

Outcome Notes:

A number of randomized control trials have shown reductions in all-cause readmissions and reduced costs.

Point of Contact:
Karen Hirschman, Associate Professor
215-573-3755
hirschk@nursing.upenn.edu

The Transitional Care Model (TCM)

University of Pennsylvania School of Nursing
Bellefonte, PA
Transitional Care Model
Target 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:

The Transitional Care Model is used in 342 locations in forty-six states (AK, AL, AR, AZ, CA, CO, CT, DE, FL, GA, HI, IA, ID, IL, IN, KS, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, NV, NY, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI).

Outcome Notes:

A number of randomized control trials have shown reductions in all-cause readmissions and reduced costs.

Point of Contact:
Karen Hirschman, Associate Professor
215-573-3755
hirschk@nursing.upenn.edu

The Transitional Care Model (TCM)

University of Pennsylvania School of Nursing
Black Canyon City, AZ
Transitional Care Model
Target 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:

The Transitional Care Model is used in 342 locations in forty-six states (AK, AL, AR, AZ, CA, CO, CT, DE, FL, GA, HI, IA, ID, IL, IN, KS, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, NV, NY, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI).

Outcome Notes:

A number of randomized control trials have shown reductions in all-cause readmissions and reduced costs.

Point of Contact:
Karen Hirschman, Associate Professor
215-573-3755
hirschk@nursing.upenn.edu

The Transitional Care Model (TCM)

University of Pennsylvania School of Nursing
Crompton, RI
Transitional Care Model
Target 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:

The Transitional Care Model is used in 342 locations in forty-six states (AK, AL, AR, AZ, CA, CO, CT, DE, FL, GA, HI, IA, ID, IL, IN, KS, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, NV, NY, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI).

Outcome Notes:

A number of randomized control trials have shown reductions in all-cause readmissions and reduced costs.

Point of Contact:
Karen Hirschman, Associate Professor
215-573-3755
hirschk@nursing.upenn.edu