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:
Independence at Home
Independence at HomePhiladelphia, PATarget Population: - Frail Older Adults
Insurance: - Medicare
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 Geriatrics202-877-0576Eric.K.DeJonge@Medstar.net
Independence at Home
Independence at HomePortland, ORTarget Population: - Frail Older Adults
Insurance: - Medicare
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 Geriatrics202-877-0576Eric.K.DeJonge@Medstar.net
Independence at Home
Independence at HomeRichmond, VATarget Population: - Frail Older Adults
Insurance: - Medicare
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 Geriatrics202-877-0576Eric.K.DeJonge@Medstar.net
Independence at Home
Independence at HomeWashington, DCTarget Population: - Frail Older Adults
Insurance: - Medicare
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 Geriatrics202-877-0576Eric.K.DeJonge@Medstar.net
Independence at Home
Independence at HomeWest Allis, WITarget Population: - Frail Older Adults
Insurance: - Medicare
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 Geriatrics202-877-0576Eric.K.DeJonge@Medstar.net
Independence at Home
Independence at HomeWestbury, NYTarget Population: - Frail Older Adults
Insurance: - Medicare
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 Geriatrics202-877-0576Eric.K.DeJonge@Medstar.net
Independence at Home
Independence at HomeWilmington, DETarget Population: - Frail Older Adults
Insurance: - Medicare
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 Geriatrics202-877-0576Eric.K.DeJonge@Medstar.net
GRACE Team Care
Indiana University School of Medicine - IU GeriatricsAnn Arbor, MITarget Population: - Frail Older Adults
- People with Multiple Chronic Conditions
Insurance: - Medicare
- 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
- One lead point of contact
- Shares information across care team/health providers
- Engages in performance measurement/quality
Replicated Sites: The GRACE Team Care program has been replicated in twenty-two sites in ten cities (Ann Arbor, MI; Atlanta, GA; Cleveland, OH; Indiapolis, IN; Los Angeles, CA; New Haven, CT; San Francisco, CA; San Mateo, CA, Whittier, CA, and eight sites Michigan) around the country.
Outcome Notes: Studies have shown reduced ED utilization, hospital admissions, 30-day readmissions, and fewer bed days of care for enrollees, along with increased self-rated health, and reduced costs.
Point of Contact: Dawn Butler, Director IU Geriatrics GRACE Training & Resource Center317-880-6577butlerde@iu.edu
GRACE Team Care
Indiana University School of Medicine - IU GeriatricsAtlanta, GATarget Population: - Frail Older Adults
- People with Multiple Chronic Conditions
Insurance: - Medicare
- 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
- One lead point of contact
- Shares information across care team/health providers
- Engages in performance measurement/quality
Replicated Sites: The GRACE Team Care program has been replicated in twenty-two sites in ten cities (Ann Arbor, MI; Atlanta, GA; Cleveland, OH; Indiapolis, IN; Los Angeles, CA; New Haven, CT; San Francisco, CA; San Mateo, CA, Whittier, CA, and eight sites Michigan) around the country.
Outcome Notes: Studies have shown reduced ED utilization, hospital admissions, 30-day readmissions, and fewer bed days of care for enrollees, along with increased self-rated health, and reduced costs.
Point of Contact: Dawn Butler, Director IU Geriatrics GRACE Training & Resource Center317-880-6577butlerde@iu.edu
GRACE Team Care
Indiana University School of Medicine - IU GeriatricsCleveland, OHTarget Population: - Frail Older Adults
- People with Multiple Chronic Conditions
Insurance: - Medicare
- 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
- One lead point of contact
- Shares information across care team/health providers
- Engages in performance measurement/quality
Replicated Sites: The GRACE Team Care program has been replicated in twenty-two sites in ten cities (Ann Arbor, MI; Atlanta, GA; Cleveland, OH; Indiapolis, IN; Los Angeles, CA; New Haven, CT; San Francisco, CA; San Mateo, CA, Whittier, CA, and eight sites Michigan) around the country.
Outcome Notes: Studies have shown reduced ED utilization, hospital admissions, 30-day readmissions, and fewer bed days of care for enrollees, along with increased self-rated health, and reduced costs.
Point of Contact: Dawn Butler, Director IU Geriatrics GRACE Training & Resource Center317-880-6577butlerde@iu.edu
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:
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.
GRACE Team Care
- Frail Older Adults
- People with Multiple Chronic Conditions
- Medicare
- 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
- One lead point of contact
- Shares information across care team/health providers
- Engages in performance measurement/quality
The GRACE Team Care program has been replicated in twenty-two sites in ten cities (Ann Arbor, MI; Atlanta, GA; Cleveland, OH; Indiapolis, IN; Los Angeles, CA; New Haven, CT; San Francisco, CA; San Mateo, CA, Whittier, CA, and eight sites Michigan) around the country.
Studies have shown reduced ED utilization, hospital admissions, 30-day readmissions, and fewer bed days of care for enrollees, along with increased self-rated health, and reduced costs.
GRACE Team Care
- Frail Older Adults
- People with Multiple Chronic Conditions
- Medicare
- 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
- One lead point of contact
- Shares information across care team/health providers
- Engages in performance measurement/quality
The GRACE Team Care program has been replicated in twenty-two sites in ten cities (Ann Arbor, MI; Atlanta, GA; Cleveland, OH; Indiapolis, IN; Los Angeles, CA; New Haven, CT; San Francisco, CA; San Mateo, CA, Whittier, CA, and eight sites Michigan) around the country.
Studies have shown reduced ED utilization, hospital admissions, 30-day readmissions, and fewer bed days of care for enrollees, along with increased self-rated health, and reduced costs.
GRACE Team Care
- Frail Older Adults
- People with Multiple Chronic Conditions
- Medicare
- 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
- One lead point of contact
- Shares information across care team/health providers
- Engages in performance measurement/quality
The GRACE Team Care program has been replicated in twenty-two sites in ten cities (Ann Arbor, MI; Atlanta, GA; Cleveland, OH; Indiapolis, IN; Los Angeles, CA; New Haven, CT; San Francisco, CA; San Mateo, CA, Whittier, CA, and eight sites Michigan) around the country.
Studies have shown reduced ED utilization, hospital admissions, 30-day readmissions, and fewer bed days of care for enrollees, along with increased self-rated health, and reduced costs.