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 AffairsLos Angeles, 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 AffairsManchester, NHTarget 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 AffairsMiami, FLTarget 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 AffairsAlbuquerque, NMTarget 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 AffairsMinneapolis, MNTarget 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 AffairsAtlanta, GATarget 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 AffairsMontrose, NYTarget 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 AffairsAugusta, GATarget 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 AffairsNew Bedford, MATarget 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 AffairsAugusta, METarget 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.