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:
Program of All-inclusive Care for the Elderly (PACE)
National PACE AssociationNorth Fork, 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
- Shares information across care team/health providers
- Education for providers and patient
- Engages in performance measurement/quality
Replicated Sites: PACE has been replicated in 233 locations in thirty-one states (AL, AR, CA, CO, DE, FL, IA, IN, KS, LA, MA, MD, MI, NC, ND, NE, NJ, NM, NY, OH, OK, OR, PA, RI, SC, TN, TX, VA, WA, WI, WY).
Outcome Notes: Studies have shown: reduced hospital readmissions; lower ED utilization; reductions in the use of institutional care; cost savings; and high levels of enrollee satisfaction.
Point of Contact: Robert Greenwood, Senior Vice Presient of Public Affairs703-535-1522Robertg@npaonline.org
Program of All-inclusive Care for the Elderly (PACE)
National PACE AssociationLake George, COTarget 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
- Shares information across care team/health providers
- Education for providers and patient
- Engages in performance measurement/quality
Replicated Sites: PACE has been replicated in 233 locations in thirty-one states (AL, AR, CA, CO, DE, FL, IA, IN, KS, LA, MA, MD, MI, NC, ND, NE, NJ, NM, NY, OH, OK, OR, PA, RI, SC, TN, TX, VA, WA, WI, WY).
Outcome Notes: Studies have shown: reduced hospital readmissions; lower ED utilization; reductions in the use of institutional care; cost savings; and high levels of enrollee satisfaction.
Point of Contact: Robert Greenwood, Senior Vice Presient of Public Affairs703-535-1522Robertg@npaonline.org
Program of All-inclusive Care for the Elderly (PACE)
National PACE AssociationDover, DETarget 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
- Shares information across care team/health providers
- Education for providers and patient
- Engages in performance measurement/quality
Replicated Sites: PACE has been replicated in 233 locations in thirty-one states (AL, AR, CA, CO, DE, FL, IA, IN, KS, LA, MA, MD, MI, NC, ND, NE, NJ, NM, NY, OH, OK, OR, PA, RI, SC, TN, TX, VA, WA, WI, WY).
Outcome Notes: Studies have shown: reduced hospital readmissions; lower ED utilization; reductions in the use of institutional care; cost savings; and high levels of enrollee satisfaction.
Point of Contact: Robert Greenwood, Senior Vice Presient of Public Affairs703-535-1522Robertg@npaonline.org
Program of All-inclusive Care for the Elderly (PACE)
National PACE AssociationBrooksville, FLTarget 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
- Shares information across care team/health providers
- Education for providers and patient
- Engages in performance measurement/quality
Replicated Sites: PACE has been replicated in 233 locations in thirty-one states (AL, AR, CA, CO, DE, FL, IA, IN, KS, LA, MA, MD, MI, NC, ND, NE, NJ, NM, NY, OH, OK, OR, PA, RI, SC, TN, TX, VA, WA, WI, WY).
Outcome Notes: Studies have shown: reduced hospital readmissions; lower ED utilization; reductions in the use of institutional care; cost savings; and high levels of enrollee satisfaction.
Point of Contact: Robert Greenwood, Senior Vice Presient of Public Affairs703-535-1522Robertg@npaonline.org
Program of All-inclusive Care for the Elderly (PACE)
National PACE AssociationAmes, IATarget 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
- Shares information across care team/health providers
- Education for providers and patient
- Engages in performance measurement/quality
Replicated Sites: PACE has been replicated in 233 locations in thirty-one states (AL, AR, CA, CO, DE, FL, IA, IN, KS, LA, MA, MD, MI, NC, ND, NE, NJ, NM, NY, OH, OK, OR, PA, RI, SC, TN, TX, VA, WA, WI, WY).
Outcome Notes: Studies have shown: reduced hospital readmissions; lower ED utilization; reductions in the use of institutional care; cost savings; and high levels of enrollee satisfaction.
Point of Contact: Robert Greenwood, Senior Vice Presient of Public Affairs703-535-1522Robertg@npaonline.org
Program of All-inclusive Care for the Elderly (PACE)
National PACE AssociationAvon, INTarget 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
- Shares information across care team/health providers
- Education for providers and patient
- Engages in performance measurement/quality
Replicated Sites: PACE has been replicated in 233 locations in thirty-one states (AL, AR, CA, CO, DE, FL, IA, IN, KS, LA, MA, MD, MI, NC, ND, NE, NJ, NM, NY, OH, OK, OR, PA, RI, SC, TN, TX, VA, WA, WI, WY).
Outcome Notes: Studies have shown: reduced hospital readmissions; lower ED utilization; reductions in the use of institutional care; cost savings; and high levels of enrollee satisfaction.
Point of Contact: Robert Greenwood, Senior Vice Presient of Public Affairs703-535-1522Robertg@npaonline.org
Program of All-inclusive Care for the Elderly (PACE)
National PACE AssociationClaflin, KSTarget 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
- Shares information across care team/health providers
- Education for providers and patient
- Engages in performance measurement/quality
Replicated Sites: PACE has been replicated in 233 locations in thirty-one states (AL, AR, CA, CO, DE, FL, IA, IN, KS, LA, MA, MD, MI, NC, ND, NE, NJ, NM, NY, OH, OK, OR, PA, RI, SC, TN, TX, VA, WA, WI, WY).
Outcome Notes: Studies have shown: reduced hospital readmissions; lower ED utilization; reductions in the use of institutional care; cost savings; and high levels of enrollee satisfaction.
Point of Contact: Robert Greenwood, Senior Vice Presient of Public Affairs703-535-1522Robertg@npaonline.org
Program of All-inclusive Care for the Elderly (PACE)
National PACE AssociationMarksville, LATarget 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
- Shares information across care team/health providers
- Education for providers and patient
- Engages in performance measurement/quality
Replicated Sites: PACE has been replicated in 233 locations in thirty-one states (AL, AR, CA, CO, DE, FL, IA, IN, KS, LA, MA, MD, MI, NC, ND, NE, NJ, NM, NY, OH, OK, OR, PA, RI, SC, TN, TX, VA, WA, WI, WY).
Outcome Notes: Studies have shown: reduced hospital readmissions; lower ED utilization; reductions in the use of institutional care; cost savings; and high levels of enrollee satisfaction.
Point of Contact: Robert Greenwood, Senior Vice Presient of Public Affairs703-535-1522Robertg@npaonline.org
Program of All-inclusive Care for the Elderly (PACE)
National PACE AssociationRutland, 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
- Shares information across care team/health providers
- Education for providers and patient
- Engages in performance measurement/quality
Replicated Sites: PACE has been replicated in 233 locations in thirty-one states (AL, AR, CA, CO, DE, FL, IA, IN, KS, LA, MA, MD, MI, NC, ND, NE, NJ, NM, NY, OH, OK, OR, PA, RI, SC, TN, TX, VA, WA, WI, WY).
Outcome Notes: Studies have shown: reduced hospital readmissions; lower ED utilization; reductions in the use of institutional care; cost savings; and high levels of enrollee satisfaction.
Point of Contact: Robert Greenwood, Senior Vice Presient of Public Affairs703-535-1522Robertg@npaonline.org
Program of All-inclusive Care for the Elderly (PACE)
National PACE AssociationDavidsonville, MDTarget 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
- Shares information across care team/health providers
- Education for providers and patient
- Engages in performance measurement/quality
Replicated Sites: PACE has been replicated in 233 locations in thirty-one states (AL, AR, CA, CO, DE, FL, IA, IN, KS, LA, MA, MD, MI, NC, ND, NE, NJ, NM, NY, OH, OK, OR, PA, RI, SC, TN, TX, VA, WA, WI, WY).
Outcome Notes: Studies have shown: reduced hospital readmissions; lower ED utilization; reductions in the use of institutional care; cost savings; and high levels of enrollee satisfaction.
Point of Contact: Robert Greenwood, Senior Vice Presient of Public Affairs703-535-1522Robertg@npaonline.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:
Program of All-inclusive Care for the Elderly (PACE)
- 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
- Shares information across care team/health providers
- Education for providers and patient
- Engages in performance measurement/quality
PACE has been replicated in 233 locations in thirty-one states (AL, AR, CA, CO, DE, FL, IA, IN, KS, LA, MA, MD, MI, NC, ND, NE, NJ, NM, NY, OH, OK, OR, PA, RI, SC, TN, TX, VA, WA, WI, WY).
Studies have shown: reduced hospital readmissions; lower ED utilization; reductions in the use of institutional care; cost savings; and high levels of enrollee satisfaction.
Program of All-inclusive Care for the Elderly (PACE)
- 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
- Shares information across care team/health providers
- Education for providers and patient
- Engages in performance measurement/quality
PACE has been replicated in 233 locations in thirty-one states (AL, AR, CA, CO, DE, FL, IA, IN, KS, LA, MA, MD, MI, NC, ND, NE, NJ, NM, NY, OH, OK, OR, PA, RI, SC, TN, TX, VA, WA, WI, WY).
Studies have shown: reduced hospital readmissions; lower ED utilization; reductions in the use of institutional care; cost savings; and high levels of enrollee satisfaction.
Program of All-inclusive Care for the Elderly (PACE)
- 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
- Shares information across care team/health providers
- Education for providers and patient
- Engages in performance measurement/quality
PACE has been replicated in 233 locations in thirty-one states (AL, AR, CA, CO, DE, FL, IA, IN, KS, LA, MA, MD, MI, NC, ND, NE, NJ, NM, NY, OH, OK, OR, PA, RI, SC, TN, TX, VA, WA, WI, WY).
Studies have shown: reduced hospital readmissions; lower ED utilization; reductions in the use of institutional care; cost savings; and high levels of enrollee satisfaction.
Program of All-inclusive Care for the Elderly (PACE)
- 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
- Shares information across care team/health providers
- Education for providers and patient
- Engages in performance measurement/quality
PACE has been replicated in 233 locations in thirty-one states (AL, AR, CA, CO, DE, FL, IA, IN, KS, LA, MA, MD, MI, NC, ND, NE, NJ, NM, NY, OH, OK, OR, PA, RI, SC, TN, TX, VA, WA, WI, WY).
Studies have shown: reduced hospital readmissions; lower ED utilization; reductions in the use of institutional care; cost savings; and high levels of enrollee satisfaction.
Program of All-inclusive Care for the Elderly (PACE)
- 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
- Shares information across care team/health providers
- Education for providers and patient
- Engages in performance measurement/quality
PACE has been replicated in 233 locations in thirty-one states (AL, AR, CA, CO, DE, FL, IA, IN, KS, LA, MA, MD, MI, NC, ND, NE, NJ, NM, NY, OH, OK, OR, PA, RI, SC, TN, TX, VA, WA, WI, WY).
Studies have shown: reduced hospital readmissions; lower ED utilization; reductions in the use of institutional care; cost savings; and high levels of enrollee satisfaction.
Program of All-inclusive Care for the Elderly (PACE)
- 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
- Shares information across care team/health providers
- Education for providers and patient
- Engages in performance measurement/quality
PACE has been replicated in 233 locations in thirty-one states (AL, AR, CA, CO, DE, FL, IA, IN, KS, LA, MA, MD, MI, NC, ND, NE, NJ, NM, NY, OH, OK, OR, PA, RI, SC, TN, TX, VA, WA, WI, WY).
Studies have shown: reduced hospital readmissions; lower ED utilization; reductions in the use of institutional care; cost savings; and high levels of enrollee satisfaction.
Program of All-inclusive Care for the Elderly (PACE)
- 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
- Shares information across care team/health providers
- Education for providers and patient
- Engages in performance measurement/quality
PACE has been replicated in 233 locations in thirty-one states (AL, AR, CA, CO, DE, FL, IA, IN, KS, LA, MA, MD, MI, NC, ND, NE, NJ, NM, NY, OH, OK, OR, PA, RI, SC, TN, TX, VA, WA, WI, WY).
Studies have shown: reduced hospital readmissions; lower ED utilization; reductions in the use of institutional care; cost savings; and high levels of enrollee satisfaction.
Program of All-inclusive Care for the Elderly (PACE)
- 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
- Shares information across care team/health providers
- Education for providers and patient
- Engages in performance measurement/quality
PACE has been replicated in 233 locations in thirty-one states (AL, AR, CA, CO, DE, FL, IA, IN, KS, LA, MA, MD, MI, NC, ND, NE, NJ, NM, NY, OH, OK, OR, PA, RI, SC, TN, TX, VA, WA, WI, WY).
Studies have shown: reduced hospital readmissions; lower ED utilization; reductions in the use of institutional care; cost savings; and high levels of enrollee satisfaction.
Program of All-inclusive Care for the Elderly (PACE)
- 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
- Shares information across care team/health providers
- Education for providers and patient
- Engages in performance measurement/quality
PACE has been replicated in 233 locations in thirty-one states (AL, AR, CA, CO, DE, FL, IA, IN, KS, LA, MA, MD, MI, NC, ND, NE, NJ, NM, NY, OH, OK, OR, PA, RI, SC, TN, TX, VA, WA, WI, WY).
Studies have shown: reduced hospital readmissions; lower ED utilization; reductions in the use of institutional care; cost savings; and high levels of enrollee satisfaction.
Program of All-inclusive Care for the Elderly (PACE)
- 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
- Shares information across care team/health providers
- Education for providers and patient
- Engages in performance measurement/quality
PACE has been replicated in 233 locations in thirty-one states (AL, AR, CA, CO, DE, FL, IA, IN, KS, LA, MA, MD, MI, NC, ND, NE, NJ, NM, NY, OH, OK, OR, PA, RI, SC, TN, TX, VA, WA, WI, WY).
Studies have shown: reduced hospital readmissions; lower ED utilization; reductions in the use of institutional care; cost savings; and high levels of enrollee satisfaction.