Why invest in redesigning care for people with complex needs?
57 Resources
State Map
Use the filters below to locate, learn about, and connect with complex care programs based on categories such as target population, care model, and other important features. Multiple category characteristics can be selected. These programs were identified by the Center for Health Care Strategies. The Playbook welcomes submissions from the field; learn how to submit your program to the Playbook.
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Priority Care Center
Humboldt IPA
Eureka, CA
Target Population:
- People with Multiple Chronic Conditions
- People with Advanced 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
- Shares information across care team/health providers
- Education for providers and patient
- Engages in performance measurement/quality
Replicated Sites:
Humboldt IPA's Priority Care Center has not been replicated.
Outcome Notes:
Early results suggest a reduction of inpatient hospitalizations.
Point of Contact:
Jane Brown , Operations Manager
707-442-0478
jbrown@humboldtipa.com
Independence at Home
Independence at Home
Westbury, NY
Target Population:
- Frail Older Adults
Insurance:
- Medicare
Quality of Evidence:
Promising
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:
The Independence at Home pilot has been replicated in sixteen sites around the country.
Outcome Notes:
Evaluation of the IAH Demonstration project showed extensive cost savings for participating providers, and improvement in the quality measures associated with the program.
Point of Contact:
Dr. K. Eric De Jonge, Director of Geriatrics
202-877-0576
Eric.K.DeJonge@Medstar.net
Independence at Home
Independence at Home
Wilmington, DE
Target Population:
- Frail Older Adults
Insurance:
- Medicare
Quality of Evidence:
Promising
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:
The Independence at Home pilot has been replicated in sixteen sites around the country.
Outcome Notes:
Evaluation of the IAH Demonstration project showed extensive cost savings for participating providers, and improvement in the quality measures associated with the program.
Point of Contact:
Dr. K. Eric De Jonge, Director of Geriatrics
202-877-0576
Eric.K.DeJonge@Medstar.net
Independence at Home
Independence at Home
Austin, TX
Target Population:
- Frail Older Adults
Insurance:
- Medicare
Quality of Evidence:
Promising
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:
The Independence at Home pilot has been replicated in sixteen sites around the country.
Outcome Notes:
Evaluation of the IAH Demonstration project showed extensive cost savings for participating providers, and improvement in the quality measures associated with the program.
Point of Contact:
Dr. K. Eric De Jonge, Director of Geriatrics
202-877-0576
Eric.K.DeJonge@Medstar.net
Independence at Home
Independence at Home
Boston, MA
Target Population:
- Frail Older Adults
Insurance:
- Medicare
Quality of Evidence:
Promising
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:
The Independence at Home pilot has been replicated in sixteen sites around the country.
Outcome Notes:
Evaluation of the IAH Demonstration project showed extensive cost savings for participating providers, and improvement in the quality measures associated with the program.
Point of Contact:
Dr. K. Eric De Jonge, Director of Geriatrics
202-877-0576
Eric.K.DeJonge@Medstar.net
Independence at Home
Independence at Home
Brooklyn, NY
Target Population:
- Frail Older Adults
Insurance:
- Medicare
Quality of Evidence:
Promising
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:
The Independence at Home pilot has been replicated in sixteen sites around the country.
Outcome Notes:
Evaluation of the IAH Demonstration project showed extensive cost savings for participating providers, and improvement in the quality measures associated with the program.
Point of Contact:
Dr. K. Eric De Jonge, Director of Geriatrics
202-877-0576
Eric.K.DeJonge@Medstar.net
Independence at Home
Independence at Home
Durham, NC
Target Population:
- Frail Older Adults
Insurance:
- Medicare
Quality of Evidence:
Promising
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:
The Independence at Home pilot has been replicated in sixteen sites around the country.
Outcome Notes:
Evaluation of the IAH Demonstration project showed extensive cost savings for participating providers, and improvement in the quality measures associated with the program.
Point of Contact:
Dr. K. Eric De Jonge, Director of Geriatrics
202-877-0576
Eric.K.DeJonge@Medstar.net
Independence at Home
Independence at Home
Flint, MI
Target Population:
- Frail Older Adults
Insurance:
- Medicare
Quality of Evidence:
Promising
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:
The Independence at Home pilot has been replicated in sixteen sites around the country.
Outcome Notes:
Evaluation of the IAH Demonstration project showed extensive cost savings for participating providers, and improvement in the quality measures associated with the program.
Point of Contact:
Dr. K. Eric De Jonge, Director of Geriatrics
202-877-0576
Eric.K.DeJonge@Medstar.net
Independence at Home
Independence at Home
Independence, OH
Target Population:
- Frail Older Adults
Insurance:
- Medicare
Quality of Evidence:
Promising
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:
The Independence at Home pilot has been replicated in sixteen sites around the country.
Outcome Notes:
Evaluation of the IAH Demonstration project showed extensive cost savings for participating providers, and improvement in the quality measures associated with the program.
Point of Contact:
Dr. K. Eric De Jonge, Director of Geriatrics
202-877-0576
Eric.K.DeJonge@Medstar.net
Independence at Home
Independence at Home
Irving, TX
Target Population:
- Frail Older Adults
Insurance:
- Medicare
Quality of Evidence:
Promising
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:
The Independence at Home pilot has been replicated in sixteen sites around the country.
Outcome Notes:
Evaluation of the IAH Demonstration project showed extensive cost savings for participating providers, and improvement in the quality measures associated with the program.
Point of Contact:
Dr. K. Eric De Jonge, Director of Geriatrics
202-877-0576
Eric.K.DeJonge@Medstar.net
Key Questions
Find curated resources about promising approaches to improving care for people with complex needs.
Who are people with complex needs?
42 Resources
What care models are promising?
91 Resources
What practical tools can I use to redesign care?
18 Practical Plays