Complex Care Programs By State
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:
Priority Care Center
- People with Multiple Chronic Conditions
- People with Serious Illness
- Medicare
- 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
Humboldt IPA's Priority Care Center has not been replicated.
Early results suggest a reduction of inpatient hospitalizations.
Independence at Home
- Frail Older Adults
- Medicare
- 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
The Independence at Home pilot has been replicated in sixteen sites around the country.
Evaluation of the IAH Demonstration project showed extensive cost savings for participating providers, and improvement in the quality measures associated with the program.
Independence at Home
- Frail Older Adults
- Medicare
- 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
The Independence at Home pilot has been replicated in sixteen sites around the country.
Evaluation of the IAH Demonstration project showed extensive cost savings for participating providers, and improvement in the quality measures associated with the program.
Independence at Home
- Frail Older Adults
- Medicare
- 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
The Independence at Home pilot has been replicated in sixteen sites around the country.
Evaluation of the IAH Demonstration project showed extensive cost savings for participating providers, and improvement in the quality measures associated with the program.
Independence at Home
- Frail Older Adults
- Medicare
- 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
The Independence at Home pilot has been replicated in sixteen sites around the country.
Evaluation of the IAH Demonstration project showed extensive cost savings for participating providers, and improvement in the quality measures associated with the program.
Independence at Home
- Frail Older Adults
- Medicare
- 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
The Independence at Home pilot has been replicated in sixteen sites around the country.
Evaluation of the IAH Demonstration project showed extensive cost savings for participating providers, and improvement in the quality measures associated with the program.
Independence at Home
- Frail Older Adults
- Medicare
- 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
The Independence at Home pilot has been replicated in sixteen sites around the country.
Evaluation of the IAH Demonstration project showed extensive cost savings for participating providers, and improvement in the quality measures associated with the program.
Independence at Home
- Frail Older Adults
- Medicare
- 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
The Independence at Home pilot has been replicated in sixteen sites around the country.
Evaluation of the IAH Demonstration project showed extensive cost savings for participating providers, and improvement in the quality measures associated with the program.
Independence at Home
- Frail Older Adults
- Medicare
- 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
The Independence at Home pilot has been replicated in sixteen sites around the country.
Evaluation of the IAH Demonstration project showed extensive cost savings for participating providers, and improvement in the quality measures associated with the program.
Independence at Home
- Frail Older Adults
- Medicare
- 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
The Independence at Home pilot has been replicated in sixteen sites around the country.
Evaluation of the IAH Demonstration project showed extensive cost savings for participating providers, and improvement in the quality measures associated with the program.