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:
Interventions to Reduce Acute Care Transfers (INTERACT)
Florida Atlantic UniversityCadillac, MITarget 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
- 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 INTERACT Model is used in 264 locations across thirty-four states.
Outcome Notes: Studies have shown reduced unnecessary hospitalizations and emergency department visits.
Point of Contact: Joseph Ouslander, MD, Professor561-297-0975jousland@health.fau.edu
Interventions to Reduce Acute Care Transfers (INTERACT)
Florida Atlantic UniversityBrainerd, MNTarget 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
- 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 INTERACT Model is used in 264 locations across thirty-four states.
Outcome Notes: Studies have shown reduced unnecessary hospitalizations and emergency department visits.
Point of Contact: Joseph Ouslander, MD, Professor561-297-0975jousland@health.fau.edu
Interventions to Reduce Acute Care Transfers (INTERACT)
Florida Atlantic UniversityJefferson City, MOTarget 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
- 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 INTERACT Model is used in 264 locations across thirty-four states.
Outcome Notes: Studies have shown reduced unnecessary hospitalizations and emergency department visits.
Point of Contact: Joseph Ouslander, MD, Professor561-297-0975jousland@health.fau.edu
Interventions to Reduce Acute Care Transfers (INTERACT)
Florida Atlantic UniversitySanford, NCTarget 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
- 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 INTERACT Model is used in 264 locations across thirty-four states.
Outcome Notes: Studies have shown reduced unnecessary hospitalizations and emergency department visits.
Point of Contact: Joseph Ouslander, MD, Professor561-297-0975jousland@health.fau.edu
Interventions to Reduce Acute Care Transfers (INTERACT)
Florida Atlantic UniversityJackson, 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
- 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
- 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 INTERACT Model is used in 264 locations across thirty-four states.
Outcome Notes: Studies have shown reduced unnecessary hospitalizations and emergency department visits.
Point of Contact: Joseph Ouslander, MD, Professor561-297-0975jousland@health.fau.edu
Pathways to Health
Health Care Access NowCincinnati, OHTarget Population: - Adults Under 65 with Disabilities
- People with Multiple Chronic Conditions
Insurance: - Medicare
- 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: Pathways to Health has not been replicated.
Outcome Notes: Preliminary data have shown a continuous decrease in frequency of visits and admissions among program participants.
Point of Contact: Judith Warren, CEO513-707-5696jwarren@healthcareaccessnow.org
Advanced Preventive Care
Health Quality PartnersDoylestown, PATarget Population: - People with Multiple Chronic Conditions
- People with Serious Illness
Insurance: - Medicare
- 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: Health Quality Partners's program originated in Doylestown, Pennsylvania, and has been replicated in Portland, Maine.
Outcome Notes: A randomized control trial showed all cause mortality reduced 22-34% depending on risk group and duration; other research has shown: reduced hospitalizations; ER visits; and Medicare costs after program fees for appropriately targeted higher-risk populations.
Point of Contact: Ken Coburn, MD, DrPH, FACP, CEO and Medical Director908-432-1102coburn@hqp.org
Advanced Preventive Care
Health Quality PartnersPortland, METarget Population: - People with Multiple Chronic Conditions
- People with Serious Illness
Insurance: - Medicare
- 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: Health Quality Partners's program originated in Doylestown, Pennsylvania, and has been replicated in Portland, Maine.
Outcome Notes: A randomized control trial showed all cause mortality reduced 22-34% depending on risk group and duration; other research has shown: reduced hospitalizations; ER visits; and Medicare costs after program fees for appropriately targeted higher-risk populations.
Point of Contact: Ken Coburn, MD, DrPH, FACP, CEO and Medical Director908-432-1102coburn@hqp.org
Access Health
HealthCare Access Maryland Baltimore, MDTarget Population: - Adults Under 65 with Disabilities
- People with Multiple Chronic Conditions
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: This program has not been replicated.
Outcome Notes: Preliminary results show a decrease in ED utilization and increases in patients identifying primary care providers.
Point of Contact: Traci Kodeck, CEO 410-627-4234tkodeck@hcamaryland.org
Coordinated Care Center
Hennepin HealthMinneapolis, MNTarget Population: - People with Multiple Chronic Conditions
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: Hennepin Health's Coordinated Care Center has not been replicated.
Outcome Notes: Preliminary data show a reduction in ED visits, an increase in outpatient utilizaiton, and improvements in the number of patients receiving optimal diabetes, vascular, and asthma care.
Point of Contact: Ross Owen, Health Strategy Director612-543-1324ross.owen@hennepin.us
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:
Interventions to Reduce Acute Care Transfers (INTERACT)
- 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
- One lead point of contact
- Shares information across care team/health providers
- Education for providers and patient
- Engages in performance measurement/quality
The INTERACT Model is used in 264 locations across thirty-four states.
Studies have shown reduced unnecessary hospitalizations and emergency department visits.
Interventions to Reduce Acute Care Transfers (INTERACT)
- 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
- One lead point of contact
- Shares information across care team/health providers
- Education for providers and patient
- Engages in performance measurement/quality
The INTERACT Model is used in 264 locations across thirty-four states.
Studies have shown reduced unnecessary hospitalizations and emergency department visits.
Interventions to Reduce Acute Care Transfers (INTERACT)
- 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
- One lead point of contact
- Shares information across care team/health providers
- Education for providers and patient
- Engages in performance measurement/quality
The INTERACT Model is used in 264 locations across thirty-four states.
Studies have shown reduced unnecessary hospitalizations and emergency department visits.
Interventions to Reduce Acute Care Transfers (INTERACT)
- 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
- One lead point of contact
- Shares information across care team/health providers
- Education for providers and patient
- Engages in performance measurement/quality
The INTERACT Model is used in 264 locations across thirty-four states.
Studies have shown reduced unnecessary hospitalizations and emergency department visits.
Interventions to Reduce Acute Care Transfers (INTERACT)
- 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
- One lead point of contact
- Shares information across care team/health providers
- Education for providers and patient
- Engages in performance measurement/quality
The INTERACT Model is used in 264 locations across thirty-four states.
Studies have shown reduced unnecessary hospitalizations and emergency department visits.
Pathways to Health
- Adults Under 65 with Disabilities
- People with Multiple Chronic Conditions
- Medicare
- 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
Pathways to Health has not been replicated.
Preliminary data have shown a continuous decrease in frequency of visits and admissions among program participants.
Advanced Preventive Care
- People with Multiple Chronic Conditions
- People with Serious Illness
- Medicare
- 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
Health Quality Partners's program originated in Doylestown, Pennsylvania, and has been replicated in Portland, Maine.
A randomized control trial showed all cause mortality reduced 22-34% depending on risk group and duration; other research has shown: reduced hospitalizations; ER visits; and Medicare costs after program fees for appropriately targeted higher-risk populations.
Advanced Preventive Care
- People with Multiple Chronic Conditions
- People with Serious Illness
- Medicare
- 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
Health Quality Partners's program originated in Doylestown, Pennsylvania, and has been replicated in Portland, Maine.
A randomized control trial showed all cause mortality reduced 22-34% depending on risk group and duration; other research has shown: reduced hospitalizations; ER visits; and Medicare costs after program fees for appropriately targeted higher-risk populations.
Access Health
- Adults Under 65 with Disabilities
- People with Multiple Chronic Conditions
- 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
This program has not been replicated.
Preliminary results show a decrease in ED utilization and increases in patients identifying primary care providers.
Coordinated Care Center
- People with Multiple Chronic Conditions
- 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
Hennepin Health's Coordinated Care Center has not been replicated.
Preliminary data show a reduction in ED visits, an increase in outpatient utilizaiton, and improvements in the number of patients receiving optimal diabetes, vascular, and asthma care.