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
- People with Multiple Chronic Conditions
- People with Advanced 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.
